QA Investigation Results

Pennsylvania Department of Health
CARESENSE HOME HEALTH
Health Inspection Results
CARESENSE HOME HEALTH
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:Based on the findings of an onsite unannounced home health agency Medicare recertification survey completed on October 12, 2022, Caresense Home Health, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.



Plan of Correction:




Initial Comments:

Based on the findings of an onsite, unannounced home health agency Medicare recertification survey completed on October 12, 2022, Caresense Home Health was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participations: Home Health Agencies.




Plan of Correction:




484.60(a)(1) STANDARD
Plan of care

Name - Component - 00
Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan.

Observations: Based on review of policy, medical records (MR) and interview with agency Manager the agency failed to ensure the services were provided as ordered by the physician for three (3) of seven (7) records reviewed. MR #1, #2 and #4. Review of policy completed 10/11/22 between approximately 4:00 PM and 5:30 PM revealed the following: POLICY, "Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long-range needs and resources". section: Procedure, 4. "the individualized plan of care must include the following: the frequency and duration of visits to be made". Review of personnel records completed October 11, between approximately 2:00 PM and 5:00 PM revealed: MR#1, Start of Care (SOC): 9/7/22: certification period reviewed: 9/7/22-11/5/22: Primary Diagnosis: Pulmonary Hypertension (condition in which high blood pressure affects the lungs), Sleep Apnea (condition in which an individual stops breathing while sleeping). Physician Orders: "Skilled nursing 8 hours daily/ 8 hours per night, 7 days per week for 160 days". Record did not contain documentation of a skilled nursing visit for: 9/13, 9/20, 9/21, 9/25, 9/27 10/2, 10/4, 10/5, 10/8, 10/9, 10/10, and 10/11. No documentation of notification to the physician. MR#2, SOC: 5/5/21: certification period reviewed: 9/17/22-11/15/22: Primary Diagnosis: Acute respiratory failure: Physicians Orders: "Skilled nursing 8 hours per night/ 7 days per week for 60 days". contained no visit documentation for 9/17, 9/18, 9/19, 9/20-9/25, 9/26, 10/1-3, 10/6, and 10/10. No documentation of notification to the physician. MR#4, SOC: 12/8/20: certification period reviewed: 9/29/22-11/27/22: Primary Diagnosis: Atrioventricular block (electrical blockage in the heart affecting its beating ability), Hypoxemia (low blood oxygen): Physician Orders: Skilled nursing 8 hours per night/ 7 nights per week for 60 days". contained no visit documentation for 10/1, 10/2, 10/8, and 10/9. No documentation of notification to the physician. Interview with agency Manager completed on October 12, 2022, at approximately 3:00PM confirmed the above findings.

Plan of Correction:

To ensure compliance of current agency policy 9:10, Plan of Care CMS #485 and physician orders, Caresense Home Health director of Nursing will review current patients authorized hours and hours being services by the agency. Physicians will be contacted, and orders will be obtained to reflect exact hours being services specific to frequency and duration of visits by Caresense Home Health. Education will also be provided to current and future nursing supervisors to ensure that they have knowledge of such policies for continued compliance with policy 9:10 Plan of Care CMS #485 and physician orders.
Director of nursing to review all on boarding patients' referrals, MD orders for start of services, hours of authorization and hours projected to be serviced by Caresense Home Health moving forward to ensure compliance is maintained in accordance to the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participations: Home Health Agencies.


484.100(b) STANDARD
Licensing

Name - Component - 00
(b) Standard: Licensing.
The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements.

Observations: Based on review of policy, personnel records (PR) and interview with Agency Manager the agency failed to maintain a Childline verification for staff having direct contact with children for one (1) of four (4) records reviewed. PR #1. Title, Pa. C.S. Chapter 63 (relating to the Child Protective Services Law) requires any individual applying as an employee with a program, activity or service, having direct contact with children, to obtain a Child Abuse Clearance in order to work and/or provide services. Findings include: Review of policy completed 10/11/22 between approximately 4:00 PM and 5:30 PM revealed the following: 4.7.1 LICENSE, REGISTRATION OR CERTIFICATION REQUIREMENTS, section: Policy, "Personnel files will be established and maintained on all staff". Procedure 1. " The personnel record or personnel information for an employee will include, ...criminal history check if required by law". Review of personnel records completed October 11, between approximately 10:30 AM and 12:00 PM revealed: PR #1, Date of Hire (DOH) 2-28-22, contained no documentation of a ChildLine verification. Interview with agency Manager completed on October 12, 2022, at approximately 3:00PM confirmed the above findings.

Plan of Correction:

Director of nursing will provide education to all office staff involved in the hiring process on Title, Pa. C.S. Chapter 63 (relating to the Child Protective Services Law) requires any individual applying as an employee with a program, activity or service, having direct contact with children, to obtain a Child Abuse Clearance in order to work and/or provide services. Current missing ChildLine verification for personnel file reviewed will be obtained. Compliance with Title, PA. C.S. Chapter 63 (relating to the Child Protective Services Law) will be maintained by agency for all current and future staff.
Personnel files to be reviewed by two administrative staff moving forward during the hiring process to ensure that all documents are in compliance in accordance to the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G., Chapter 601.


Initial Comments:

Based on the findings of an onsite unannounced home health agency state re-licensure survey completed on October 12, 2022, Caresense Home Health, was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G., Chapter 601.





Plan of Correction:




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 review of policy, personnel records (PR) and interview with Agency Manager the agency failed to maintain a Childline verification for staff having direct contact with children for one (1) of four (4) records reviewed. PR #1. Title, Pa. C.S. Chapter 63 (relating to the Child Protective Services Law) requires any individual applying as an employee with a program, activity or service, having direct contact with children, to obtain a Child Abuse Clearance in order to work and/or provide services. Findings include: Review of policy completed 10/11/22 between approximately 4:00 PM and 5:30 PM revealed the following: 4.7.1 LICENSE, REGISTRATION OR CERTIFICATION REQUIREMENTS, section: Policy, "Personnel files will be established and maintained on all staff". Procedure 1. " The personnel record or personnel information for an employee will include, ...criminal history check if required by law". Review of personnel records completed October 11, between approximately 10:30 AM and 12:00 PM revealed: PR #1, Date of Hire (DOH) 2-28-22, contained no documentation of a ChildLine verification. Interview with agency Manager completed on October 12, 2022, at approximately 3:00PM confirmed the above findings.

Plan of Correction:

Director of nursing will provide education to all office staff involved in the hiring process on Title, Pa. C.S. Chapter 63 (relating to the Child Protective Services Law) requires any individual applying as an employee with a program, activity or service, having direct contact with children, to obtain a Child Abuse Clearance in order to work and/or provide services. Current missing ChildLine verification for personnel file reviewed will be obtained. Compliance with Title, PA. C.S. Chapter 63 (relating to the Child Protective Services Law) will be maintained by agency for all current and future staff.

Personnel files to be reviewed by two administrative staff moving forward during the hiring process to ensure that all documents are in compliance in accordance to the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G., Chapter 601.


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 review of policy, medical records (MR) and interview with agency Manager the agency failed to ensure the services were provided as ordered by the physician for three (3) of seven (7) records reviewed. MR #1, #2 and #4. Review of policy completed 10/11/22 between approximately 4:00 PM and 5:30 PM revealed the following: POLICY, "Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long-range needs and resources". section: Procedure, 4. "the individualized plan of care must include the following: the frequency and duration of visits to be made". Review of personnel records completed October 11, between approximately 2:00 PM and 5:00 PM revealed: MR#1, Start of Care (SOC): 9/7/22: certification period reviewed: 9/7/22-11/5/22: Primary Diagnosis: Pulmonary Hypertension (condition in which high blood pressure affects the lungs), Sleep Apnea (condition in which an individual stops breathing while sleeping). Physician Orders: "Skilled nursing 8 hours daily/ 8 hours per night, 7 days per week for 160 days". Record did not contain documentation of a skilled nursing visit for: 9/13, 9/20, 9/21, 9/25, 9/27 10/2, 10/4, 10/5, 10/8, 10/9, 10/10, and 10/11. No documentation of notification to the physician. MR#2, SOC: 5/5/21: certification period reviewed: 9/17/22-11/15/22: Primary Diagnosis: Acute respiratory failure: Physicians Orders: "Skilled nursing 8 hours per night/ 7 days per week for 60 days". contained no visit documentation for 9/17, 9/18, 9/19, 9/20-9/25, 9/26, 10/1-3, 10/6, and 10/10. No documentation of notification to the physician. MR#4, SOC: 12/8/20: certification period reviewed: 9/29/22-11/27/22: Primary Diagnosis: Atrioventricular block (electrical blockage in the heart affecting its beating ability), Hypoxemia (low blood oxygen): Physician Orders: Skilled nursing 8 hours per night/ 7 nights per week for 60 days". contained no visit documentation for 10/1, 10/2, 10/8, and 10/9. No documentation of notification to the physician. Interview with agency Manager completed on October 12, 2022, at approximately 3:00PM confirmed the above findings.

Plan of Correction:

To ensure compliance of current agency policy 9:10, Policy 11:1, Plan of Care CMS #485 and physician orders, Medical Record Content, Caresense Home Health Director of Nursing will review current patients authorized hours and hours being services by the agency. Physicians will be contacted, and orders will be obtained to reflect exact hours being services specific to frequency and duration of visits by Caresense Home Health. Education will also be provided to current and future nursing supervisors to ensure that they have knowledge of such policies for continued compliance with policy 9:10 Plan of Care CMS #485 and physician orders.

Director of nursing to review all on boarding patients' referrals, MD orders for start of services, hours of authorization and hours projected to be serviced by Caresense Home Health moving forward to ensure compliance is maintained in accordance to the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participations: Home Health Agencies.


Initial Comments:Based on the findings of an onsite unannounced home health agency state re-license survey completed on October 12, 2022, Caresense Home Health, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.


Plan of Correction:




Initial Comments:Based on the findings of an onsite unannounced home health agency state re0licensure survey completed October 12, 2022, Caresense Home Health, was found to be in compliance with the requirements of 35 P. S. 448.809 (b).


Plan of Correction: