Initial Comments:
Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted on February 6, 2024 through February 8, 2024 and offsite on February 12, 2024, Mog 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:
601.31(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 clinical records (CR), agency policy, and an interview with agency ' s CEO and administrator, the agency failed to provide care according to the CMS-485 Home Health Certification and Plan of Care (POC) for four (4) of seven (7) CR reviewed (CR#3, 5, 6 and 7).
Findings include:
A review of agency ' s policy was conducted on 2/8/24 at approximately 11:00 AM and revealed the following:
Policy titled, " Policy # C-4.0 Missed Visits/Deviation from Prescribed Frequency of Services " reads in part, " PROCEDURE: 1. When any clinician misses a scheduled patient visit, or missed the visit will be documented either in the electronic computer system or on paper using the " Missed Visit Report Form (copy attached). The missed visit documentation will be completed by the clinician and forwarded to the physician via fax or electronic means. 2. A copy of the fax confirmation sheet or e-mail will be maintained along with the documentation of the missed visit report in the patients clinical record. "
A review of clinical records (CR) was conducted on 2/6/24 from approximately 1:00 PM to 3 PM and on 2/7/24 from approximately 11 AM to 3:00 PM revealed the following:
CR#3. Start of Care: 2/9/23. Discharge date: 2/27/23. Certification period reviewed: 2/9/23 - 4/9/23. File contained Physical Therapist orders for two (2) to three (3) times weekly for nine (9) weeks. During week of 2/5/23 - 2/11/23, only one (1) visit was conducted. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#5. Start of Care:8/22/23. Discharge date: 10/18/23. Certification period reviewed: 8/22/23 - 10/20/23. File contained Home Health Aide orders for four (4) hours per day, seven (7) days per week for nine (9) weeks. During week of 8/22/23 - 8/26/23, no visit was conducted but one (1) missed visit note was documented. During week of 8/27/23 - 9/2/23, no visit was conducted but two (2) missed visit notes were documented. During week of 9/3/23 - 9/9/23, 9/10/23 - 9/16/23, 9/24/23 - 9/30/24, 10/1/23 - 10/7/23, 10/8/23 - 10/14/23 and 10/15/23 - 10/18/23, no visit was conducted. File contained Occupational Therapist orders for one (1) to three (3) times weekly for nine (9) weeks. During week of 8/22/23 - 8/26/23, 8/27/23 - 9/2/23, 9/3/23 - 9/9/23, 9/10/23 - 9/16/23, 9/17/23 - 9/23/23, 9/24/23 - 9/30/23, 10/1/23 - 10/7/23, 10/8/23 - 10/14/23, 10/15/23 - 10/18/23, no visit was conducted each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#6. Start of Care: 6/7/23. Discharge Date: 7/5/23. Certification period reviewed: 6/7/23 - 8/5/23. File contained Home Health Aide orders for four (4) hours per day, three (3) days per week for nine (9) weeks. During the week 6/7/23 - 6/10/23, no visit was conducted. During week of 6/11/23 - 6/17/23 and 6/18/23 - 6/24/23, only two (2) visits were conducted each week. During week of 6/25/23 - 7/1/23, only one (1) visit was conducted. During week of 7/2/23 - 7/5/23, no visit was conducted, and CR contained 1 missed visit note. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#7. Start of Care: 8/31/23. Discharge date: 10/29/23. Certification period reviewed: 8/31/23 - 10/29/23. File contained Home Health Aide orders for eight (8) hours per day, two (2) days per week for nine (9) weeks. During certification period 8/31/23 - 10/29/23, no visit was conducted.
File contained Physical Therapy orders for one (1) to three (3) times per week for nine (9) weeks. During certification period 8/31/23 - 10/29/23, no visit was conducted.
File contained Occupational therapy orders for one (1) to three (3) times per week for nine (9) weeks. During certification period 8/31/23 - 10/29/23, no visit was conducted.
File did not contain missed visit documentation regarding above missed visits, there was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
An interview with the agency ' s administrator on 2/8/24 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:The Director of Clinical Services will provide an inservice to 100% of clinical staff by 04/11/2024 on the agency Policy # C-4.0 Missed Visits/Deviation from Prescribed Frequency of Services regarding the need to follow the physician's prescribed plan of care and when any clinician misses a scheduled patient visit, the visit will be documented either in the electronic computer system or on paper using the paper based " Missed Visit Report Form". The missed visit documentation will be completed by the clinician and forwarded to the physician via fax or electronic means. Furthermore, a copy of the fax confirmation sheet or e-mail will be maintained along with the documentation of the missed visit report in the patient's clinical record. If it is determined that the patient no longer needs or wants the services or the physician wishes to discontinue services, a verbal order to update or discontinue services will be forwarded to the physician for signature.
The agenda, supporting documents and completed staff sign-in sheets are available for review on site.
100% of current patient's charts will be audited weekly for 4 weeks by the Director of Clinical Services to ensure documented evidence in the clinical record exists that reflects:
-The agency is following the physician's ordered plan of care (CMS-485) for all discipline visits ordered.
-- If a visit was missed by any discipline (RN, PT, OT, SLP, MSW or HHA) the physician was notified with:
--a missed visit report form OR
--a verbal order to update or discontinue the order
Target Threshold = 100%. With the Director of Clinical Services responsible
If consistently met after 4 weeks of audits, will reduce audits to complete as part of clinical record review with 20% or minimum of 10 chart reviews per quarter on an ongoing basis to avoid this deficiency in the future.
The Director of Clinical Services is responsible.
Date of accomplishment 04/11/2024
Initial Comments:
Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted on February 6, 2024 through February 8, 2024 and offsite on February 12, 2024, Mog Home Healthcare Services 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 unannounced onsite Home Health Agency State Re-Licensure Survey conducted on February 6, 2024 through February 8, 2024 and offsite on February 12, 2024, Mog Home Healthcare Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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