Initial Comments:Based on the findings of an unannounced onsite home health agency Medicare recertification survey completed on December 14, 2022, Advantage Home Health and Hospice, 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 unannounced onsite home health agency Medicare recertification survey completed on December 14, 2022, Advantage Home Health and Hospice, was found to not be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies
Plan of Correction:
484.105(f)(2) ELEMENT
In accordance with current clinical practice
Name - Component - 00
All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice.
Observations:
Based on review of policy and procedure, clinical record review, and an interview with the Vice President of Compliance, it was determined the agency failed to ensure weekly wound measurements, for two (2) out of four (4) clinical records reviewed, of patients receiving skilled nursing wound care services from the agency (CR#11 and CR #17).
Review of agency policy "Wound Measurement Policy" on 12/14/2022 at approximately 2:30 PM states " ...wounds will be measured weekly and documented in patient's chart".
Review of CR#11 (Start of Care (SOC): 10/22/2022) on 12/14/2022 at approximately 9:00 AM revealed the following: A "Home Health Certification and Plan of Care" for the certification period 10/22/2022-12/20/2022 with the following wound care order: Right posterior Foot Plantar Area R great toe remove old dressing, double bag, place in trash. Cleanse ulcer with mild soap and water, pat dry, apply Betadine, cover with gauze wrap secure with tape daily and PRN detachment or increased drainage". Review of skilled nursing visits revealed wound measurements to not be recorded in the clinical record for the visit week of 11/20/2022-11/26/2022, with a skilled nursing visit conducted on 11/23/2022.
Review of CR#17(SOC: 10/26/2022) on 12/14/2022 at approximately 12:00 PM revealed the following: A "Home Health Certification and Plan of Care" for the certification period 10/26/2022-12/24/2022 with the following wound care order: "Puncture/ Left outer Foot Arch 2 pinpoint holes, cleanse area with NSS, pat dry, apply calcium alginate and cover with DSD daily. Review of skilled nursing visits revealed wound measurements to not be recorded in the clinical record for the following visit weeks, nor was the wound assessment documented as non-measurable:
10/23/2022-10/29/2022, with a skilled nursing visit conducted on 10/26/2022
10/30/2022-11/05/2022, with a skilled nursing visit conducted on 10/31/2022
11/13/2022-11/19/2022, with a skilled nursing visit conducted on 11/16/2022
11/27/2022-12/03/2022, with a skilled nursing visit conducted on 11/30/2022
An interview with the agency Vice President of Compliance on 12/14/2022 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Effective week of 12/25/2022 all field staff will be re- educated on the Policy and Procedure for wound care measurements on a weekly basis for all home health patients with skilled wound care. Handouts of the Policy and Procedure as well as wound care education will be given to all field staff.
All field staff will sign off on required re-education by 1/5/23.
All patients receiving skilled wound care from home health agency will be reviewed on a weekly bases effective week of 12/25/2022 and will be reviewed at 100% weekly until 100% x 4 consecutive weeks either by Clinical Director or qualified clinician if director is not available
Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey completed on December 14, 2022, Advantage Home Health and Hospice, was found to not be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.
Plan of Correction:
601.32 REQUIREMENT
SKILLED NURSING SERVICE
Name - Component - 00
601.32 V. SKILLED NURSING SERVICE.
Observations:
Based on review of policy and procedure, clinical record review, and an interview with the Vice President of Compliance, it was determined the agency failed to ensure weekly wound measurements, for two (2) out of four (4) clinical records reviewed, of patients receiving skilled nursing wound care services from the agency (CR#11 and CR #17).
Review of agency policy "Wound Measurement Policy" on 12/14/2022 at approximately 2:30 PM states " ...wounds will be measured weekly and documented in patient's chart".
Review of CR#11 (Start of Care (SOC): 10/22/2022) on 12/14/2022 at approximately 9:00 AM revealed the following: A "Home Health Certification and Plan of Care" for the certification period 10/22/2022-12/20/2022 with the following wound care order: Right posterior Foot Plantar Area R great toe remove old dressing, double bag, place in trash. Cleanse ulcer with mild soap and water, pat dry, apply Betadine, cover with gauze wrap secure with tape daily and PRN detachment or increased drainage". Review of skilled nursing visits revealed wound measurements to not be recorded in the clinical record for the visit week of 11/20/2022-11/26/2022, with a skilled nursing visit conducted on 11/23/2022.
Review of CR#17(SOC: 10/26/2022) on 12/14/2022 at approximately 12:00 PM revealed the following: A "Home Health Certification and Plan of Care" for the certification period 10/26/2022-12/24/2022 with the following wound care order: "Puncture/ Left outer Foot Arch 2 pinpoint holes, cleanse area with NSS, pat dry, apply calcium alginate and cover with DSD daily. Review of skilled nursing visits revealed wound measurements to not be recorded in the clinical record for the following visit weeks, nor was the wound assessment documented as non-measurable:
10/23/2022-10/29/2022, with a skilled nursing visit conducted on 10/26/2022
10/30/2022-11/05/2022, with a skilled nursing visit conducted on 10/31/2022
11/13/2022-11/19/2022, with a skilled nursing visit conducted on 11/16/2022
11/27/2022-12/03/2022, with a skilled nursing visit conducted on 11/30/2022
An interview with the agency Vice President of Compliance on 12/14/2022 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Effective week of 12/25/2022 all field staff will be re- educated on the Policy and Procedure for wound care measurements on a weekly basis for all home health patients with skilled wound care. Handouts of the Policy and Procedure as well as wound care education will be given to all field staff.
All field staff will sign off on required re-education by 1/5/23.
All patients receiving skilled wound care from home health agency will be reviewed on a weekly bases effective week of 12/25/2022 and will be reviewed at 100% weekly until 100% x 4 consecutive weeks either by Clinical Director or qualified clinician if director is not available
Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey completed on December 14, 2022, Advantage Home Health and Hospice, 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 completed on December 14, 2022, Advantage Home Health and Hospice, was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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