Initial Comments:
An onsite follow-up survey completed March 8, 2024, found that Providence Home Health Agency, Inc. had corrected the following deficiencies cited under the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The deficiencies were cited as a result of a federal recertification survey completed on January 24, 2024. As a result of the survey, the condition cited at: 484.65 Quality Assessment/Performance Improvement was lifted by verification of implementation of the approved plan of correction. Standard level deficiencies remain.
Plan of Correction:
484.55(b)(3) ELEMENT
Therapy services determine eligibility
Name - Component - 00
When physical therapy, speech-language pathology, or occupational therapy is the only service ordered by the physician or allowed practitioner, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure new orders were sent to the Physician for clinical record #2, an audit was conducted of clinical records, and a review was conducted weekly of 25% of client charts, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
"......... For Cr#2 (clinical record #2) new orders will be sent to the Physician. ....... The agency will conduct an audit of clinical records to ensure the deficient practices does not reoccur. ....... The Don (Director of Nursing) will review 25% of client charts weekly ...."
Corrective action date: 02/29/2024.
Documentation review #1: No documentation provided of obtaining new Physician orders for clinical record #2, an audit being conducted of the clinical records, and a review being conducted weekly of 25% of client charts.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:New Physician orders for clinical record #2 will be obtained. The Don (Director of Nursing) will review 25% of client charts weekly. Audit of All clinical records.
484.55(c)(5) ELEMENT
A review of all current medications
Name - Component - 00
A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure the Director of Nursing reviewed all charts, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
"...... DON (Director of Nursing) to review all charts ......."
Corrective action date: 02/29/2024.
Documentation review #1: No documentation provided of the Director of Nursing reviewed all charts.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:DON to review all charts to ensure have been reconciled.
Initial Comments:An onsite follow-up survey completed on March 8, 2024 found that Providence Home Health Agency, Inc. had corrected the deficiencies cited under the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness. The deficiencies were cited as a result of a federal recertification survey completed January 24, 2024.
Plan of Correction:
Initial Comments:
An onsite follow-up survey completed on March 8, 2024 found that Providence Home Health Agency, Inc. had not corrected the deficiencies cited under the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G. Chapter 601. The deficiencies were cited as a result of a state relicensure survey completed January 24, 2024.
Plan of Correction:
601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS
Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to obtain all federal and state background checks on EF#2 (employee #2) and EF#9 (employee #9), as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
" ........ HR (Human Resources) will obtain all federal and state background checks on EF#2, EF#9 and maintain the background checking in the employee's files ....."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of obtaining a federal criminal history report for EF#2 (employee #2) nor a Childline criminal history report for EF#9 (employee #9).
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:HR will obtain all federal and state background checks on EF#2, EF#9 and maintain the background checking in the employee's files.
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to obtain employees applicable CPR (cardio pulmonary resuscitation) training, Orientation, and TB (tuberculosis) testing, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
".... All Employees will obtain applicable ........ , CPR, Orientation, and TB testing. ........."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of employee #2, #5, #6, and #8 obtaining Orientation (utilizing the Orientation Checklist per policy) nor TB testing. No documentation provided of employee #6 obtaining CPR certification.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:Will provide update Documentation for #1: No documentation provided of employee #2, #5, #6, and #8 obtaining Orientation (utilizing the Orientation Checklist per policy) nor TB testing. No documentation provided of employee #6 obtaining CPR certification.
601.31(a) REQUIREMENT
PATIENT ACCEPTANCE
Name - Component - 00
601.31(a) Patient Acceptance.
Patients are accepted for treatment on
the basis of a reasonable expectation
that the patient's medical, nursing
and social needs can be met adequately
by the agency in the patient's place
of residence. Care follows a written
plan of treatment established and
periodically reviewed by a physician
and care continues under the general
supervision of a physician.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure the Medical Social Worker was re-educated on following MD (doctor of medicine) orders and failed to ensure the clients charts were monitored weekly, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/01/2024, revealed the following:
" ......... The agency will re-educate .......... Medical social worker on following MD orders for frequency and notifying the physician of any changes to the POC frequency...... The DON and Compliance officer will monitor the client's charts weekly for compliance with the physician's POC frequencies. ......"
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of re-educating the Medical Social Worker on following MD orders for nor of the DON (Director of Nursing) and the Compliance officer monitoring the client's charts weekly for compliance.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction: The agency will re-educate the Medical social worker on following MD orders for frequency and notifying the physician of any changes to the POC frequency. The DON and Compliance officer will monitor the client's charts weekly for compliance with the physician's POC frequencies.
601.31(b) REQUIREMENT
PLAN OF TREATMENT
Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).
If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.
Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure a weekly review of client records was conducted, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 03/04/2024, revealed the following:
" ..... The Agency DON (Director of Nursing) will review Client records weekly. ....."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of the agency DON reviewing the Client records weekly.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:Agency will Provide documentation provided of the agency DON reviewing the Client records weekly.
601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS
Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.
Observations:
Based on a review of the agency plan of correction and an interview with the agency alternate Administrator, the agency failed to ensure all client charts were reviewed weekly, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 03/08/2024 at approximately 9:30 a.m., approved by the Department on 02/20/2024, revealed the following:
" ....... All charts will be reviewed weekly......."
Corrective action date: 03/04/2024.
Documentation review #1: No documentation provided of all client charts being reviewed weekly.
An interview conducted on March 8, 2024 at approximately 11:30 a.m. with the agency alternate Administrator confirmed the above findings.
Plan of Correction:The Agency DON (Director of Nursing) will review Client records weekly.
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