Initial Comments:
An onsite follow up and State re-licensure survey completed March 13, 2024, found that A&M Healthcare Agency Llc had not corrected the deficiencies cited under requirements of 28 PA Code, Part IV, Health Facilities, Subpart G, Chapter 601. The deficiencies were cited as a result of a complaint investigation survey completed on October 26, 2023.
Plan of Correction:
601.4 REQUIREMENT
Inspections
Name - Component - 00
The home health care agency shall be subject to inspection at any time by authorized representatives of the Department. Inspections may be scheduled in advance or be unannounced.
Observations:
Based on review of the agency website, observation and staff interview (EMP), the agency failed to be subject to an unannounced inspection by the authorized representative of the Department.
Findings include;
Review of the agency's website on 3/7/24 at 1:20 p.m. showed it's hours of operation as Monday through Friday from 9:00 a.m. to 5:00 p.m.
Surveyors arrived onsite on 3/11/24 at 9:05 a.m. and the agency door was locked, the agency was called and a message was left. At 9:34 a.m. the Vice President (EMP1) returned the call and indicated the office was closed and there was no one available who could assist for a survey, and she would not be available until the following day and that the Administrator is out of town.
Plan of Correction:The agency's hours of operation are Monday through Friday, 9 am to 5 pm.
If for any reason outside of public holidays, the office needs to be closed, the agency will notify the Department of health via email 2 weeks prior and adjust our answering machine to inform callers that office will be closed for the specified period. Hours of operation will also be adjusted on business website.
Reasons for office closure are:
death, sickness, vacation or if administrator decides to close the office.
Employees 1 (vice President) & 2 (Client Care Coordinator) are assigned to be in the office during opening hours of operations. The on-call number is left on the answering machine for anyone who needs to contact a representative of A&M. Employee 2, Client Care Coordinator is assigned the on-call/emergency phone and is available during and outside business hours of operations.
Despite any office hours adjustment, an employee/representative will always be available for any unannounced inspection by an authorized representative of the Department. The compliance effective date was March 18, 2024. Employee 1 & 2 reports to administrator regarding attendance. Administrator is responsible for audit.
601.21(d) REQUIREMENT
ADMINISTRATOR
Name - Component - 00
601.21(d) Administrator. The
qualified administrator, who may also
be the supervising physician or
registered nurse: (i) organizes and
directs the agency's ongoing
functions, (ii) maintains ongoing
liaison among the governing body, the
group of professional personnel, and
the staff, (iii) employs qualified
personnel and ensures adequate staff
education and evaluations, (iv)
ensures the accuracy of public
information materials and activities,
and (v) implements an effective
budgeting and accounting system. A
qualified person is authorized in
writing to act in the absence of the
administrator.
Observations:
Based on review of documentation of the Home Health agency and clinical records (CR) and interview with agency staff (EMP) the agency failed to demonstrate the presence of systematic data collection and monitoring of infections, failed to display the current Provisional Certificate of License.
Findings include:
Review of Clinical Record #1 on 3/12/24, at 10:30 a.m. indicated start of care date was 9/1/22, review of certification period from 3/8/24 to 5/8/24, revealed a physician 60 day summary that indicated "patient was put on a new medication for having yeast infection on 1/10/24."
Review of Clinical Record #4 on 3/12/24, at 1:00 p.m. indicated start of care date was 2/7/21, review of certification period from 1/12/24 to 3/12/24, revealed a physician 60 day summary report that indicated "patient was diagnosed with a urinary tract infection on 12/4/23."
A review of the agency Infection Control Management and Assessment Policy on 3/13/24, at 12:50 p.m. indicated the QAPI Department will log and monitor all reported infections and assess for trends and patterns. Infections may include agency or community acquired infections and will be evaluated for possible causes of infections and common factors that could lead to transmission. The infection program will include surveillance, identification, prevention, control, and reporting.
Review of the agency Infection Log binder on 3/13/24 at 1:00 p.m. revealed that it did not include any documentation on CR1 and CR4 infections and the last documented infection in the binder was on 12/21/21, for a Covid19 positive patient. No further documented evidence provided by the HHA to support an agency-wide program for the surveillance, identification, prevention, control, and reporting of infections.
During an interview on 3/13/24 at 2:25 p.m. the agency Vice President (EMP1) confirmed the above findings.
During an observation on 3/13/24, at 2:36 p.m. the agency Certificate of Licensure on display dated 2/1/23 to 1/31/24, was not the current Provisional Certificate of License, dated 10/26/23 to 4/26/24.
During an interview on 3/13/24, at 2:37 p.m. the agency Vice President confirmed the agency failed to display the current Provisional Certificate of License.
Plan of Correction:As of 3/13/2024, current Provisional Certificate of License is on display mounted on wall. Employee 1 is responsible for licensing. Effective March 13, 2024, staff has 5 days to display each new license once it has been approved. Administrator to review quarterly to ensure correct license is displayed.
QAPI Department (administrator, Vice-President, Clent care coordinator and medical director) will log and monitor all reported infections and assess for trends and patterns. Monitoring will include possible causes of infections and common factors that could lead to transmission, surveillance, identification, prevention, control, and reporting of all infections and bacteria related diseases.
Nurse's education was completed on 3/18/2024.
Infection control log will be audited in quarterly meetings and annual reviews with medical director. Medical director will audit trends and causes for infections.
Initial audit and medical will be completed by qapi on 4/26/2024. All medical patients file will be reviewed during audit to assess infection control monitoring.
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 personnel files (PF) and an interview with agency staff (EMP), the agency failed to ensure that employee qualifications, specifically CPR [cardio-pulmonary resuscitation], were kept current for two (2) of four (4) personnel files reviewed (PF1, PF2)and the agency failed to demonstrate the presence of annual TB education for one (1) of four (4) PFs reviewed (PF1).
Findings include:
Review of agency policy titled, "CPR Administration, Cardio-pulmonary Resuscitation" on 3/12/24 at approximately 11:45 a.m. indicated, Policy: "It shall be the policy of this agency that field personnel must be currently certified in cardio-pulmonary resuscitation (CPR) before administering the procedure to a patient..."
Review of agency policy titled, "Employee File" on 3/12/24 at approximately 11:45 a.m. indicated, Policy: Every agency employee will have a personnel record...Procedure: ...
B. The following information will be included in the personnel record:... 2. Current PPD Form...4. CPR certification-Need current copy when hired..."
In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf).
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of agency policy titled, "Employee Annual TB Testing" on 3/12/24 at approximately 11:45 a.m. indicated, Policy: Any employee who has patient contact is tested annually for tuberculosis infection (TB)...Procedure...2. Annually each employee will: (a) Receive a tuberculosis skin test (PPD) ...(b) Known reactors may submit a copy of previous chest x-ray if available and will complete the tuberculosis questionnaire on an annual basis...
A review of personnel files conducted on 3/12/24 at approximately 10:15 a.m. to 11:30 a.m. revealed:
PF1, Date of hire 1/1/14. PF1 Registered Nurse provided documentation of a CPR certification with an expiration date of 4/22/18. There was no additional documentation to show that PF1 had a current CPR certification. PF1 did not include documentation of annual TB education for 2023 or 2024.
PF2, Date of hire 3/5/19. PF2 Registered Nurse provided documentation of a CPR certification with an expiration date of 1/1/22. There was no additional documentation to show that PF2 had a current CPR certification.
Interview on 3/12/24 at approximately 12:00 p.m. with the agency Vice President confirmed the above findings.
Plan of Correction:On March 15, 2024, CPR certificate was received for 1 of the 2 personnel files reviewed. The deadline to have all personnel record updated is 4/1/2024.
On March 27, 2024, the annual TB results for 1 the personnel file was received.
Agency will continue to have employees tested annually for TB as well as have each new hire complete 2 step TB prior to start of employment.
On March 18, 2024, administrative staff was trained on maintaining employee personnel files. Training included monitoring CPR and TB expiration. Vice president and Client Care Coordinator will be responsible for maintaining employee's files.
Deadline for all employees' files to be updated is April 19, 2024.
TB and CPR tracking and teaching will be completed during our annual trainings with employees. All employees will be notified one month prior to annual trainings for all expired documentation or upcoming expired documentation. On the day of staff training all employees will be expected to sign off the submission of required documents.
601.22(a) REQUIREMENT
ANNUAL POLICY REVIEW
Name - Component - 00
601.22(a) Annual Policy Review. A
group of professional personnel, which
includes at least one practicing
physician and one registered nurse,
and with appropriate representation
from other professional disciplines,
establishes and annually reviews the
agency's policies governing scope of
services offered, admission and
discharge policies, medical
supervision and plans of treatment,
emergency scope of services offered,
medical care, clinical records,
personnel qualifications, and program
evaluation.
Observations:
Based on review of the Home Health Agency (HHA) documentation , review of policy and procedure and interview with agency staff (EMP1) it was determined the agency failed to ensure the group of professional personnel reviewed the agency's policies annually.
Findings include:
Review of agency documention titled, "Quality Management Plan" on 3/12/24 at approximately 1:30 p.m. to 2:00 p.m. indicated, " Overview: The Quality Management Plan provides A&M Healthcare (A&M) with a systematic, objective and continuous process for monitoring, evaluating and improving the quality and appropriateness of the service delivered within the agency...Structure and Functions...D. The Quality Management Program of A&M provides the structure for the agency to: evaluate the efficiency of the organization's functioning, evaluate services provided by A&M, set goals and objectives for the organization to continue to improve services, ensure compliance with all laws, rules, policies and procedures for service implementation...assure compliance with PA regulations..."
Review of agency Policy: AO.006 "Administrative Responsibilities" on 3/12/24 at approximately 1:30 p.m. to 2:00 p.m. indicated, "Policy: A&M Healthcare Agency LLC maintains administrative control and established lines of authority for delegation of responsibility concerning the delivery of patient care and services. Procedure:...The Administrator may act on behalf of the Governing Body for any function or matter regarding the agency..."
Review of Job Description CEO/Administrator on 3/12/24 at approximately 1:30 p.m. to 2:00 p.m. Position Summary: "CEO/Administrator is responsible for the...planning and overall administration of the organization. The CEO/Administrator is accountable for all activities and departments....Summary of Job Functions: Ensures that policies and procedures meet Federal, State, local and accrediting organization's regulations and standards..."
Review of agency Approval of Policies & Procedures Manual on 3/12/24 at approximately 1:30 p.m. to 2:00 p.m. revealed, Policy and Procedures Manual. Approved by the Governing Board. Effective Date October 2016, signed by the Administrator... No documented evidence that the agency policies were reviewed 2017 through 2023.
Interview on 3/12/24 at approximately 2:00 p.m. with the agency Vice President confirmed the above findings.
Plan of Correction:Administrator is responsible for reviewing and approving all updated policies and procedures.
On March 27, 2024, Administrator and Vice President reviewed Agency current policies and procedures. Administrator signed and dated updated policies and procedures.
An audit will be completed annually during Agency's annual meeting with Medical Director (Dr. YB) on May 15, 2024, to ensure agencies policies and procedures are in compliance with the Department of Health.
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of agency policy and clinical record and staff employee (EMP) interview, the agency failed to ensure nursing visit records included completed wound assessments by a Registered Nurse for one (1) of six (6) clinical records reviewed (CR2).
Findings include:
Review of agency policy and clinical record (CR) on 3/12/24 at 12:52 p.m. revealed the following:
The agency policy "Wound Assessment and Documentation" indicated wound assessment and documentation must be completed by Registered Nurse or Licensed Practical Nurse .... Ongoing assessment of the individual, their wound and the healing environment is required to monitor the effectiveness of wound prevention and intervention .... Wound Assessments includes: wound size including longest length, widest width and deepest depth ... Take wound measurements at least once a week, or when there is a change in the status of the wound.
CR2, Start of Care 9/18/18, review of the Home Health Certification and Plan of Care, certification period 1/19/24, to 3/19/24, indicated the physician ordered skilled nursing to perform wound care every Tuesday, Thursday, Saturday and Sunday. The Physician 60 Day Summary which was included indicated patient will continue to need skilled nursing for wound care to two (2) stage four ulcers.
Review of all available Nursing Visit Records for CR1 for the above certification period revealed Registered Nurse (PF2) completed all visits and all the forms failed to contain documentation of weekly wound measurements to include length, width and depth.
During an interview with the agency Vice President (EMP1), confirmed the above findings and called Registered Nurse (PF2) who confirmed that she did not complete wound measurements for CR2.
Plan of Correction:Administrator had meeting with PF2 regarding failure to document wound measurements on March 15, 2024.
Administrator will access RNs compliance regarding wound care during the 60 days audits. Wound care will continuously be reviewed by the administrator while completing form 485 (plan of care) every 60 days for doctor to review and sign.
Date of completion is 4/30/2024.
601.36(a) REQUIREMENT
MAINTENANCE AND CONTENT OF RECORD
Name - Component - 00
601.36(a) Maintenance and Content of
Record. A clinical record is
maintained in accordance with accepted
professional standards and contains:
(i) pertinent past and current
findings,
(ii) plan of treatment,
(iii) appropriate identifying
information,
(iv) name of physician,
(v) drug, dietary, treatment and
activity orders,
(vi) signed and dated clinical
progress notes (clinical notes are
written the day service is rendered
and incorporated no less often than
weekly),
(vii) copies of summary reports sent
to the physician, and
(viii) a discharge summary.
Observations:
Based on review of clinical records (CR) and staff interviews (EMP), the agency failed to maintain clinical records or provide a completed list of current patients in accordance with accepted professional standards for seven (7) of seven (7) clinical records reviewed (CR1-CR7).
Findings include:
During Entrance Conference with the agency on 3/12/24 at 9:11 a.m. the agency Vice President (EMP1) was asked to furnish a list of current patients, with start of care date, diagnosis, and current certification period.
On 3/12/24, at 9:40 a.m. The Vice President furnished the surveyor team with a list indicating they currently had four patients on service, CR1, CR3, CR4 and CR5 and the list did not include diagnosis, start of care date, or current certification period information. The Vice president then brought several binders left them in a stack on the table indicated that they are the clinical records of current patients.
A review of clinical records on 3/12/24 from approximately 10:30 a.m. to 2:24 p.m. revealed the following:
CR2 and CR6 clinical records were sitting in the stack and not on the list of current patients. Further review of all clinical records for CR1, CR2, CR3, CR4, CR5, and CR6 revealed that Home Health Certifications and Plans of Care were randomly placed in a large pocket in the binders, some were copies of faxes sent to the physician and not signed and other were signed returned copies in random order without any consideration of filing them in some type of order such as time or date. In another pocket were Nursing Visit Records covering several two (2) month certification periods which were randomly placed in the pocket without any consideration of filing them in some type of order such as time or date..
On 3/12/24, at 12:13 p.m. the Vice President (EMP1) confirmed that CR2 and CR6 were not on the list of current patients she provided.
On 3/12/24, at 2:24 p.m. the Vice President confirmed that the agency did not have system of placing Home Health Certifications and Plans of Care or Nursing Visit notes in patients records in accordance with accepted standards of practice, and instead randomly placed them in the records, and during this time a Nursing Visit Note dated 3/8/24 was discovered, this patient did not appear on the list of current patients, and was identified as CR7 and the Vice President confirmed that CR7 was currently on service and she forgot to add CR7 to the list of current patients provided at entrance.
Plan of Correction:Agency needs to be prepared for unscheduled audits and investigations.
After administrator meeting with vice president and client care coordinator on March 23,2024, a sign out sheet system has been implemented for employees removing files from filing cabinet. Every time a patient file is removed from filing cabinet, it needs to be signed out, with date, time, individual responsible for file and location of file.
Client Care coordinator is responsible for filing nursing notes and clinical records. Nursing notes and clinical records will be filed according to dates. Expected date of completion is 4/30/2024.
Initial Comments:
Based on the findings of an unannounced onsite home care agency state re-licensure and revisit survey conducted on March 13, 2024, A&M Healthcare Agency 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 unannounced onsite home care agency state re-licensure and revisit survey conducted on March 13, 2024, A&M Healthcare Agency Llc, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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