Initial Comments:
An onsite follow up and State relicensure survey completed on April 3, 2025, found that A&M Healthcare Agency Llc had not corrected the following deficiencies cited under requirements of 28 PA Code, Part IV, Health Facilities, Subpart G, Chapter 601. The deficiencies were cited as a result of an unannounced complaint investigation survey completed on October 26, 2023, an onsite follow up and State re-licensure survey completed March 13, 2024, and an onsite follow up survey completed on June 11, 2024, and onsite follow up and relicensure survey completed September 26, 2024.
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 1/22/25, at 9:07 a.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 1/22/25 at 9:43 a.m. and the agency door was locked, the agency was called and a message was left. At 10:21 a.m. the Vice President EMP1 returned the call and indicated she was onsite, the surveyor then returned onsite, at that time the Vice President EMP1 indicated she might have COVID-19 (a disease caused by a virus named SARS-CoV-2), and the Administrator was not available for the week.
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 and adjust answering machine to inform callers that office will be closed for the specified period.
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, the agency will try to ensure an employee/representative be available for any unannounced inspection by an authorized representative of the Department. The compliance effective date was April 25, 2025. 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 agency approved Plan of Correction, policy, clinical records and employee files and Administrator interview, it was determined that the Administrator failed to organize and direct the agency's ongoing functions and maintain a liaison among the governing body, group of professional personnel and the staff. Specifically, the administrator failed to ensure audits and agency staff trainings were completed as per Plan of Correction and annually, that an annual budget was completed, physician orders were obtained, ensure nursing visit records were completed.
Findings include:
1. The agency failed to provide training and proof of competencies related to related to peripherally inserted central catheters and intravenous medications as per Plan of Correction (POC). Failed to ensure personnel files were complete. Cross reference 1007: Personnel Policies - 601.21(f).
2. The agency governing body failed to prepare an annual operating budget. Cross reference 1010 - 601.21(d).
3. Failed to complete POC directed audits. The agency failed to obtain and follow physician orders. Failed to ensure nurses completed visit as ordered by the physician. Cross Reference 1020 Conformance with Physician Orders - 601.31(d).
4. Failed to complete POC directed training for initial assessments and nursing visit records and failed to complete clinical records. Cross Reference 1023 Duties of the Registered Nurse - 601.32(b)
5. Failed to complete POC directed training. Cross Reference 1035 Maintenance and Content of Record - 601.36(a)
6. Failed to completed POC directed training. Ch. 51 009 Notifications - 51.3(g)(1-14)
Plan of Correction:1. Training and competency test related to related to peripherally inserted central catheters and intravenous medications was completed April 18, 2025. Test will be included in nursing annual trainings. 6/3/2025
2.Budget for agency was completed on April 16, 2024. Moving forward annual budget will be completed and signed off by agency's medical director during annual audits and meeting with medical director. 6/3/2025
3. Plan of care audits were completed on April 17, 2025. POCs were corrected to match physician orders as well on April 17, 2025. POC audits will be completed every 60 days while completing renewed POCs.
4. Administrator is responsible for completeing POC as of 4/9/2025
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 agency submitted plan of correction for deficiencies issued from the follow up and State relicensure survey completed 9/26/24, and interview with agency staff (EMP), the agency failed to correct deficient practice as stated on the approved Plan of Correction specifically by failing to provide training or documentation of training related to peripherally inserted central catheters and intravenous medications for two (2) of three (3) employee file reviews of Registered Nurses (EF2 and EF3) and the agency failed to ensure personnel files were complete including but not limited to: providing annual TB education, annual performance evaluations and current CPR (cardiopulmonary resuscitation) certification for three (3) of three (3) personnel files reviewed of field personnel (EF1, EF2 and EF3)
Findings include:
Agency submitted plan of correction (POC), M1007 ...completion date 11/1/24 (agency's date of alleged compliance) ...1. training related to peripherally inserted central catheters (PICC - long thin flexible tube inserted through veins in the arm to a large vein in the chest, one use is for long term antibiotics) and intravenous medications (IV - medication administered into the vein) is scheduled for 10/24/24 to all RN's. Training will be signed by each individual RN on staff.
Review of agency policy "Employee Files" on 4/1/25, 10:25 a. m. indicated the following information will be included in the personnel record: ... 4. CPR certification ... 15. evaluations.
Review of Agency Policy "Employee Evaluations" on 4/12/25, at 10:25 a.m. indicated evaluations will be conducted annually.
Review of agency policy "CPR Administration Cardio-Pulmonary Resuscitation" on 4/1/25, 10:25 a. m. indicated : "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 "Home IntraVenous therapy and first dose drug procedure" on 4/1/25, at 10:25 a.m.. indicated Intravenous therapy shall be provided by a qualified licensed nurse having knowledge and documented competency to interpret and implement written orders. The IV may be initiated by a Registered Nurse ... who has demonstrated technical competence through an approved training program which includes 1. potential injection sites 2) expected action of therapy 3) potential side effects 4) infection control practices sterile techniques 5. emergency action 6. return demonstration of accessing a vein appropriately.
The CDC guidelines state that all Health Care Workers (HCW) should receive 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...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. CDC Guidelines for preventing the 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).
Employee Files reviews (EF) conducted on 4/1/25, at 11:45 a.m. and 4/2/25, at 9:20 a.m. revealed the following:
EF1, Home Health Aide, Date of Hire 8/13/15, did not contain documentation of a current CPR certification or annual TB education and an annual performance evaluation completed in 2024.
EF2, Registered Nurse, Date of Hire 10/28/23, contained a document titled "Home Health Aide Training - Annual Training Sign Off", the block for "Peripherally Inserted Central Catheter and Intravenous Medications" indicating completion of training was not dated. Did not contain an annual performance evaluation completed in 2024.
EF3,Registered Nurse, Date of Hire 10/17/19, contained a document titled "Home Health Aide Visit Note - Annual Training Sign Off", did not contain a block or sign off area for "Peripherally Inserted Central Catheter and Intravenous Medications". Did not contain an annual performance evaluation completed in 2024.
A review on 4/2/25, at 9:32 a.m. an agency supplied document titled "Agency PICC Line Training" contained 31 pages on information on PICC lines, and indicated "Nurses dressing or flushing or using a PICC for intravenous therapy should be trained appropriately and have achieved competency" but did contain a competency or evaluation skills section for staff.
During an interview on 4/2/25, at 10:52 a.m. EMP1 Vice President indicated that the training sign off for agency RN's were for Home Health Aides and she modified them, she gave EF3, the wrong annual training document and it did not contain a block or sign off area for "Peripherally Inserted Central Catheter and Intravenous Medications", and couldn't provide documentation for competency or evaluation of skills section on "Peripherally Inserted Central Catheter and Intravenous Medications"
During a phone interview on 4/3/25, at 10:08 a.m. EF2, was asked if she was provided "Peripherally Inserted Central Catheter and Intravenous Medications" training, by the Home Health Agency, she indicated she had training at a local hospital, and then indicated the Administrator calls her by phone to do training.
During an interview with the Administrator on 4/3/25, at 10:22 a.m. the Administrator refused interview walked out of the room and did not answer questions or employee files or training.
Plan of Correction:EF1, Home Health Aide, Date of Hire 8/13/15, submitted current CPR certification on 4/16/2025 and it has been placed in file. Annual TB reading was requested for EF1 to be submitted by 4/28/205 and Annual evaluation was completed on 4/16/2025
EF2, Registered Nurse, Date of Hire 10/28/23, is being registered with Care Academy for 40 hour continuing training to meet the requirements for RNs working for Pennsylvania Healthcare. Annual performance evaluation was completed on 4/16/2025.
EF3,Registered Nurse, Date of Hire 10/17/19, is being registered with Care Academy for 40 hour continuing training to meet the requirements for RNs working for Pennsylvania Healthcare. Annual performance evaluation was completed on 4/16/2025.
Administrator will review employee files during annual training to ensure all training are completed, along with Updated nursing license, CPR and TB requirements.
6/3/2025
601.21(i) REQUIREMENT
INSTITUTIONAL PLANNING
Name - Component - 00
601.21(i) Institutional Planning.
The home health agency under the
direction of the governing body,
prepares an overall plan and budget
which provides for an annual operating
budget.
Observations:
Based on a review of the professional advisory committee (PAC) meeting minutes and staff (EMP) interview, the committee, under the direction of the governing body did not prepare an annual operating budget.
Findings include
A review of the PAC meeting minutes was conducted on 4/2/25, at 11:13 a.m.. The minutes dated 7/11/24, did not contain an annual operating budget.
During an interview 4/3/25, at 10:55 a.m. EMP1 the Vice President confirmed there was no documentation of overall plan to include budget planning documented for this agency in the above meeting minutes.
Plan of Correction:Budget for agency was completed on April 16, 2024. Moving forward annual budget will be completed and signed off by agency's medical director during annual audits and meeting with medical director. 6/3/2025
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 submitted plan of correction for deficiencies issued from the follow up survey completed 9/26/24, and interview with agency staff (EMP), the agency failed to correct deficient practice by not providing audits as stated on the approved Plan of Correction and failed to follow physician orders for three (3) of four (4) clinical records reviewed (CR1, CR3 and CR4).
Findings include:
Agency submitted plan of correction (POC), M1020 ... completion date 11/1/24 (agency's date of alleged compliance) ... "as of October 3rd, 2024, based on audits completed on all patients by administrator, all doctor's orders were submitted and signed. Administrator will audit nursing notes every 90 days.
Review of Facility Audit on 4/1/25 at 10:34 a.m. furnished by EMP1 the Vice President that confirmed "this is the only audit I have that she did it but did not sign or date it" that they have no other audits, immediate review of the audit revealed the following:
CR1, Home Health Certification and Plan of Care (POC) reviewed on 1/11/25 for certification period 1/11/25 to 3/11/25.
CR2 POC reviewed on 1/24/25 for certification period 1/24/25 to 3/24/25.
CR3 POC reviewed on 1/18/25 for certification period 1/18/25 to 3/18/25.
CR4 POC reviewed on 1/15/25 for certification period 1/15/25 to 3/15/25.
Audit contained areas of audits for missed visits and missing notes, all were marked 'N/A' (not applicable).
Review of agency policy "Physician Communication and Receiving Orders" on 4/1/25, 10:25 a. m. indicated It shall be the policy of this agency to establish clearly defined procedures for contacting a patient's physician, receiving orders and documenting all communication both written and verbal. Procedure: All communication with the physician shall be documented in the medical record. Communication with a patient's physician is required in the following cases: In situations where there has been a change in the established frequency.
Review of agency policy "Medication Administration" on 4/1/25, 10:25 a. m. indicated It shall be policy of this agency that nurses follow acceptable standards of practice when administering medications. Procedure: The patient's physician must order administration of medication...Medication administration will be documented in the medical record...physician will be notified on any medications not administered...General Guidelines: During the admission process and throughout the course of care the nurse will view all current medications the patient is taking...all of which must be verified with the physician.
Review of CR1 clinical record on 4/2/25 at 11:51 a.m. revealed the following:
Start of Care date 9/1/22, diagnosis Paraplegia (paralysis of lower part of the body)
CR1's Home Health Certification and Plan of Care (POC) for certification period 1/13/24 to 3/12/24, signed by the Administrator on 1/21/25 and the physician on 1/22/25, indicated Skilled Nursing to perform wound care 4-5 times a week for 2 hours a visit as needed. Message (Massage) closed wound areas with A&D ointment per visit.
During an interview on 4/2/25, at 1:09 p.m. EMP1 the Vice President confirmed that CR1's POC read 1/13/24 to 3/12/24, and had the incorrect year, which should be 2025.
CR1's POC for certification period of 3/12/25 to 5/13/25, signed by the Administrator on 3/19/25 and not signed by the physician, indicated Skilled Nursing to perform wound care 4-5 times a week for 2 hours a visit as needed. Message (Massage) closed wound areas with A&D ointment per visit.
A review of Nursing Visit Records (Documentation of care provided and date the visit was provided by Nurse) for CR1 from 1/5/25 to 3/22/25 revealed the following number of Nursing Visit Records per week starting on Sundays:
1/5/25 (Sunday) three
1/12/25, three
1/19/25, one
1/26/25, two
2/2/25 two
2/9/25 one
2/16/25 four
2/23/25, two
3/2/25, three nursing visit records with two records both dated 3/31/25.
3/9/25, no documented nursing visit records for this week.
3/16/25, one
During an interview on 4/3/25, EMP1 the Vice President confirmed the above findings and indicated CR1's is ordered three visits a week, that the POC indicated she is ordered 5 visits a week.
A review of CR3's clinical record on 4/2/25, at 1:17 p.m. revealed the following:
Start of Care date 9/30/21, diagnosis Cerebrovascular Accident with Left Hemiplegia (Stroke with left sided weakness).
CR3's POC for certification period 1/18/25 to 3/19/25, signed by the Administrator on 1/22/25 and the Physician on 1/28/25, indicated Skilled Nursing 1-2 visits per week to refill medication dispenser machine, Administer Actemra 162 MG (MilliGrams)/0.9 ML (MillLiters) inject subcutaneously every 14 days (Order did not include diagnosis).
CR3's POC for period 3/18/25 to 5/20/25, signed by the Administrator on 3/24/25 and the physician on 3/27/25, indicated Skilled Nursing 1-2 visits per week to refill medication dispenser machine, Administer Actemra 162 MG./0.9 ML inject subcutaneously every 14 days (Order did not include diagnosis).
A review of Nursing Visit Records (Documentation of care provided including injecting medications and the date the visit was provided by nurse) for CR3 from 1/19/25 to week ending 3/22/25 revealed the following number of Nursing Visit Records per week starting on Sundays (All visit completed by EMP3 RN):
2/16/25, (Sunday) no documented nursing visit records for the week.
2/23/25, no documented nursing visit records for the week.
Further Review of CR3's nursing visit records revealed Actemra was administered by the nurse on the following dates:
1/15/25, Actemra administered
1/21/25, notes indicated no injection today, will fill out paperwork to get Actemra injection.
1/31/25, 16 days after last administration.
2/5/25, 5 days after last administration.
2/12/25, 7 days after last administration.
3/7/25, 23 days after last administration.
3/13/25, 6 days after last administration.
3/18/25, 5 days after last administration.
During an interview on 4/3/25. at 9:40 a.m. EMP1 the Vice President confirmed the above findings for CR3 and was asked to clarify days of administration for CR3's Actemra, she indicated it was every 7 days and handed over a "Physician Order" for Actemra injection 162mg/0.9 ml weekly instead of two weeks, diagnosis indicated Lupus (disease that occurs when your body's immune system attacks your own tissues and organs), with EMP3 RN signature on it dated 1/4/24 (1 year earlier), and confirmed that it was not signed by the physician.
During an interview 4/3/25, at 10:08 a.m. with EMP1 the Vice President in person and EMP3 RN by phone, both indicated the Actemra is supposed to be administered every 7 days, that the above POC's are incorrect. That the missed doses are due to CR3 having appointments or being out of town and the daughter does not like to give injections.
During an interview on 4/3/25 at 10:22 p.m. the Admistrator was asked to clarify concerns on CR3's Actemra, did not know the diagnosis it was treating and refused further interview and walked out of the room.
A review of CR4's clinical record on 4/2/23 at 2:02 p.m. revealed the following:
Start of Care date 2/7/21, diagnosis Dementia (decline in cognitive abilities and memory loss).
CR4's POC for period 1/16/25 to 3/17/25 signed by the Administrator on 1/22/25, signed by the physician 1/28/25, indicated skilled nursing to perform 2 hour visit 3 times a week.
A review of Nursing Visit Records (Documentation of care provided and date the visit was provided by Nurse) for CR3 from 1/19/25 to 3/22/25 revealed the following number of Nursing Visit Records per week starting on Sundays:
1/19/25, no documented nursing visit records for this week.
1/26/25, four nursing visit records with two both dated 1/31/25.
3/2/25, two
3/9/25, one
3/16/25, four nursing visit records for the week with two both dated 3/16/25.
During an interview on 4/2/25, at 2:20 p.m. EMP1 the Vice President confirmed the above findings for CR4.
Plan of Correction:The administrator is responsible for maintaining proper client documentation and clinical records as required. Administrator will monitor, coordinate, and review documentation weekly. If reviews are greater than 80% of meeting requirements, then agency will proceed to quarterly reviews.
All patient's documentation in files including 60-day summaries, POCs, and physician orders will be updated by June 3, 2025.
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 submitted plan of correction (POC) for deficiencies issued from the follow up and State relicensure survey completed 9/26/24, and interview with agency staff (EMP), the agency failed to provide documentation of Plan of Correction directed annual training on completing initial assessments and visit records for two (2) of three (3) personal files reviewed (EF2 and EF3), and failed to complete nursing visit records for three (3) of four (4) clinical records reviewed.
Findings include:
Agency submitted plan of correction (POC), M1023 ... completion date 11/10/24 (agency's date of alleged compliance) ...Administrator will implement annual training on completing initial assessment and visit records.
Review of employee files (EF) conducted on 4/1/25, at 11:45 a.m. and 4/2/25, at 9:20 a.m. revealed the following:
EF2, Registered Nurse, Date of Hire 1/14/18, did not contain documentation of annual training on completing initial assessment and visit records for 2024.
EF3, Registered Nurse, Date of Hire 10/19/19, did not contain documentation of annual training on completing initial assessment and visit records training for 2024.
During an interview on 4/2/25, at 10:52 a.m. EMP1 the Vice President confirmed the agency did not have documentation of annual training for 2024 on completing initial assessments and visits records for EF2 and EF3 .
Review of CR1 clinical record on 4/2/25 at 11:51 a.m. revealed the following:
Start of Care date 9/1/22, diagnosis Paraplegia (paralysis of lower part of the body).
CR1's Home Health Certification and Plan of Care (POC) for certification period 1/13/24 to 3/12/24, signed by the Administrator on 1/21/25 and the physician on 1/22/25, indicated Skilled Nursing to perform wound areas 4-5 times a week for 2 hours a visit as needed.
During an interview on 4/2/25, at 1:09 p.m. EMP1 the Vice President confirmed that CR1's POC read 1/13/24 to 3/12/24, and had the incorrect year, which should be 2025.
CR1's POC for certification period of 3/12/25 to 5/13/25, signed by the Administrator on 3/19/25 and not signed by the physician, indicated Skilled Nursing to perform wound areas 4-5 times a week for 2 hours a visit as needed.
A review of Nursing Visit Records (Documentation of care provided and date the visit was provided by Nurse) for CR1 from 1/5/25 to 3/22/25 revealed the following number of Nursing Visit Records per week starting on Sundays:
1/5/25 (Sunday) three
1/12/25, three
1/19/25, one
1/26/25, two
2/2/25 two
2/9/25 one
2/16/25 four
2/23/25, two
3/2/25, three nursing visit records with two records both dated 3/31/25.
3/9/25, no documented nursing visit records for this week.
3/16/25, one
During an interview on 4/3/25, EMP1 the Vice President confirmed the above findings and indicated CR1's is ordered three visits a week, that the POC indicated she is ordered 5 visits a week.
A review of CR3's clinical record on 4/2/25, at 1:17 p.m. revealed the following:
Start of Care date 9/30/21, diagnosis Cerebrovascular Accident with Left Hemiplegia (Stroke with left sided weakness)
A review of Nursing Visit Records for CR3 from 1/19/25 to week ending 3/22/25 revealed the following number of Nursing Visit Records per week starting on Sundays:
2/16/25 (Sunday) no documented nursing visit records for the week.
2/23/25 no documented nursing visit records.
During an interview 4/3/25, at 10:08 a.m. with EMP1 the Vice President confirmed the above findings for CR3.
A review of CR4's clinical record on 4/2/23 at 2:02 p.m. revealed the following:
Start of Care date 2/7/21, diagnosis Dementia (decline in cognitive abilities and memory loss)
CR4's POC for period 1/16/25 to 3/17/25, signed by the Administrator on 1/22/25, signed by the physician 1/28/25, indicated skilled nursing to perform 2 hour visit 3 times a week.
A review of Nursing Visit Records (Documentation of care provided and date the visit was provided by Nurse) for CR3 from 1/19/25 to 3/22/25, revealed the following number of Nursing Visit Records per week starting on Sundays:
1/19/25, no documented nursing visit records for this week.
1/26/25, four nursing visit records with two both dated 1/31/25.
3/2/25 two
3/9/25 one
3/16/25 four nursing visit records for the week with two both dated 3/16/25.
During an interview on 4/2/25, at 2:20 p.m. EMP1 the Vice President confirmed the above findings for CR4.
Plan of Correction:Employee 1 & 2 are being registered with Care Academy for 40 hour continuing training to meet the requirements for RNs working for Pennsylvania Healthcare.
Care Academy will be an annual training requirement for all RNS on staff. RNS and administrator will receive annual email reminders from Care Academy for trainings.
Administrator will also remind RNS to complete training once reminder notifications has been received.
6.3.2025
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 agency submitted plan of correction for deficiencies issued from the follow up and State relicensure survey completed 9/26/24, and interview with vice president (VP) and agency staff (EMP), it was determined the agency failed to correct deficient practice specifically by not providing training of Registered Nurses to inform the administrator of patient deaths for two (2) of three (3) employee files reviewed of Registered Nurses (EF2 and EF3).
Findings include:
Agency submitted plan of correction (POC), M1035 ... completion date 11/1/24 (agency's date of alleged compliance) ...VP, client care coordination, and RN's have been trained to inform admistrator of patient deaths within 24 hours.
Review of employee files (EF) conducted on 4/1/25, at 11:45 a.m. and 4/2/25, at 9:20 a.m. revealed the following:
EF2, Registered Nurse, Date of Hire 1/14/18, did not contain documentation of training to inform administrator of patient death within 24 hours.
EF3, Registered Nurse, Date of Hire 10/19/19, did not contain documentation of training to inform administrator of patient death within 24 hours.
During an interview on 4/2/25, at 10:52 a.m. EMP1 the Vice President confirmed the agency did not have documentation of training to inform administrator of patient deaths within 24 hours for EF2 and EF3.
During an interview on 4/3/25 at 10:22 p.m. the Administrator was asked to clarify concerns. Administrator refused further interview and walked out of the room.
Plan of Correction:Employee 1 & 2 are being registered with Care Academy for 40 hour continuing training to meet the requirements for RNs working for Pennsylvania Healthcare.
Care Academy will be an annual training requirement for all RNS on staff. RNS and administrator will receive annual email reminders from Care Academy for trainings.
Administrator is responsible for training and will also remind RNS to complete training once reminder notifications has been received.
Notification of patient death in included in the agency's annual critical incident trainings which are completed annually with all employees.
6.3.2025
Initial Comments:
An onsite follow up and State relicensure survey completed on April 3, 2025, found that A&M Healthcare Agency Llc, had not corrected the following deficiency with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A. The deficiency was cited as a result of an unannounced onsite follow up and relicensure survey completed September 26, 2024.
Plan of Correction:
51.3 (g)(1-14) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on review of the agency approved plan of correction, employee file review and staff interviews (EMP), it was determined the agency failed to correct deficient practice by not providing documentation of annual training on incidents for two (2) of three (3) employee file reviews of Registered Nurses (EF2 and EF3).
Findings include:
Agency submitted plan of correction (POC), H009 51.3 ... completion date 11/15/24 (agency's date of alleged compliance) ...Annual staff training with all staff including Registered Nurse, Administrative staff ... will be implemented.
Review of employee files (EF) conducted on 4/1/25, at 11:45 a.m. and 4/2/25, at 9:20 a.m. revealed the following:
During an interview on 4/2/25, EMP1 the Vice President indicated employees took an annual inservice quiz on Annual Critical Incidents, and provided a document "Annual Critical Incident 2020"
Review of agency packet "Annual Critical Incident 2020" 4/2/25, at 10:51 a.m. revealed a 56 page document providing education and training on Prevention of Abuse and Exploitation of Participants, included on pages 51 to 53 was annual in-service quiz that indicated a score of 100% is required to pass the quiz.
EF2, Registered Nurse, Date of Hire 1/14/18, contained an annual service quiz dated 2/4/25 with a score of 85%. Did not contain an annual inservice quiz for 2024.
EF3, Registered Nurse, Date of Hire 10/19/19, did not contain an annual inservice quiz for 2024.
During an interview on 4/2/25, at 9:20 a.m. EMP1 the Vice President confirmed the above findings.
Plan of Correction:Employee 1 & 2 completed the "Annual Critical Incident 2020" quiz and sign off sheet on April 11, 2025.
Employee 1 & 2 are being registered with Care Academy for 40 hour continuing training to meet the requirements for RNs working for Pennsylvania Healthcare.
Care Academy will be an annual training requirement for all RNS on staff. RNS and administrator will receive annual email reminders from Care Academy for trainings.
Administrator is responsible for trainings and will also remind RNS to complete training once reminder notifications has been received.
The "Annual Critical Incident" training is, and internal training completed by all employees annually.
6.3.2025
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