Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted March 5, 2025 and concluded offsite on March 12, 2025, Amazing Care Home Health Services, LLC., 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:
601.31(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 review of agency policy, clinical record (CR) reviews, and interview with agency staff, the agency failed to obtain a physician's signature on the Home Health Certification and Plan of Care (POC) in accordance with agency policy for two (2) of five (5) CR reviewed. (CR #2 & 5) and the agency did not provide care according to the plan of care/physician orders for one (1) of five (5) CRs. (CR# 3).
Findings include:
On 3/5/25 and 3/12/25 at approximately 8:00AM review of agency policy revealed the following:
Policy titled, "Development of Care Plan" stated, "The plan of treatment shall be developed in consultation with the agency staff and shall cover pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations safety measures...instructions for timely discharge or referral and other appropriate items. The total plan of treatment shall be reviewed by the attending physician and home health care personnel as often as the severity of the patient's condition requires but at least once every 60 days. All patient care orders, including verbal orders, must be recorded in the plan of care. Identification of the patient's continuing need for home care and meet the patient's medical, nursing, rehabilitative and social and discharge planning needs including health needs...Agency professional staff shall promptly alert the physician to changes that suggest a need to alter the plan of treatment...The license nurse....shall immediately record and sign oral orders and obtain the physician's countersignature within 7 days...."
Policy titled, "Physican Verbal/Telephone Orders" stated, "All plans of care/treatment and verbal or telephone orders will be countersigned by the physician within seven (7) days"
Review of clinical records (CR) occurred on 3/5/25 starting at approximately 10:30 AM and revealed the following:
CR #2: Start of Care (SOC): 3/1/24. File contained Home Health Certification and Plan of Care for certification period 12/26/24-2/23/25 that was signed by the ordering physician on 2/24/25 (60 days later).
CR#3: Start of Care(SOC): 9/12/23. File contained Home Health Certification and Plan of Care for certification period 1/4/25-3/4/25 that stated skilled nursing services for 8 hours/day (56 hours per week) for 9 weeks. In reviewing the certification period above the following days did not have any skilled nursing services provided: 1/5/25, 1/12/25, 1/19/25, 1/26/25, 2/2/25, 2/9/25, 2/16/25, 2/23/25. On 3/25/25 at approximately 1:00 PM the director of nursing stated that the patient's more recent authorization for services from Office of Long Term Living (OLTL) stated 12 hours daily 6 days/week. The Director of Nursing confirmed that this change was not reflected on the current plan of care/485.
CR #5: Start of Care (SOC): 2/15/24. File contained Home Health Certification and Plan of Care for certification period 8/13/24-10/11/24 that was signed by the ordering physician on 10/2/24 (50 days later).
Interview with the Director of Nursing on 3/5/25 at approximately 2:30 PM confirmed the above findings.
Plan of Correction:Immediate corrective action to correct physician signature compliance include that the plan of care for patient #3 will be updated to reflect the most recent authorization from the Office of Long-Term Living (OLTL) and all missed visits reviewed and reconciled with documentation and physician notification by 4/4/25. By 4/11/25, all clinical and administrative staff involved in care coordination, order management, and clinical documentation will be re-educated on agency policy and regulatory requirements regarding: 1) Timely physician signature on all plans of care and verbal orders within 30 days; 2) Ensuring services are provided exactly as outlined in the plan of care; 3) Communicating changes in service authorizations or patient needs to the physician promptly and updating the plan of care accordingly. This education will be documented with a sign-in sheet for compliance tracking. A new order tracking log will be implemented by 4/11/25 to monitor physician order submission and return timelines to ensure physician signatures are obtained within the required 30-day window. A weekly chart audit process will be implemented by 4/11/25 to verify that all plans of care are signed and dated by the physician within the designated timeframe, services rendered match the frequency and scope outlined in the plan of care, and any discrepancies are flagged and resolved immediately. The Administrator or designee will monitor 100% of Plan of Care orders, order tracking log, and plan of care accuracy and adherence weekly for 3 months to ensure 100% compliance with 601.31(d). Once 100% compliance is achieved, quarterly audits of 25% of plan of care orders will be completed by the Administrator or designee for 1 year. If 100% compliance at any time is not achieved, further education and/or disciplinary action will take place and 100% of Plan of Care order audits will continue weekly for a period of 3 months. Results of the audits will be reviewed quarterly with the QAPI committee.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 5, 2025 and concluded offsite on March 12, 2025, Amazing Care Home Health Services, LLC., 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 state re-licensure survey conducted on March 5, 2025 and concluded offsite on March 12, 2025, Amazing Care Home Health Services, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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