Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted May 7, 2024 through May 8, 2024, Always Best Care, 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:
601.21(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 the agency policies, personnel files (PF), Centers for Disease Control Tuberculosis Testing Guidelines, and an interview with administrator, the agency failed to provide, completed orientation documentation for two (2) of the seven (7) PF ' s reviewed, (PF#4 and 6); TB testing, risk assessment and symptom screening upon hire (3), four (4) of the seven (7) PF ' s reviewed, (PF#1,4 and 6); Annual Tuberculosis (TB) education for four (4) of the seven (7) PF ' s reviewed, (PF# 2,5,6 and 7); Initial competency for one (1) of the seven (7) PF ' s reviewed, (PF#6 ); Annual competencies for four (4) of the seven (7) PF ' s reviewed, (PF#2,5,6 and 7); Performance evaluations for four (4) of the seven (7) PF ' s reviewed, (PF# 2,5,6 and 7); Pennsylvania State (PATCH) Background check for one (1) of the seven (7) PF ' s reviewed, (PF#5); Documentation of Child Abuse Clearance for two (2) of the seven (7) PF ' s reviewed, (PF#5 and 7)
Findings Included:
A review of agency policy titled " Human Resources " was conducted on May 8, 2024 at approximately 10:00 am states, Procedure: 3. Prior to hire, the organization will secure multiple reference checks, health reports as required by the state or policy, criminal record checks when required by law, and proof of citizenship or documentation of resident status.
A review of agency policy titled " Categories/ Qualifications of Personnel " Policy was conducted on May 8, 2024 at approximately 10:05 am states, Categories of Personnel: 7. Contract Personnel: Individuals or groups of individuals who perform services as directed in a written agreement. Contract personnel are not considered employees for purposes of overtime, longevity, benefits, etc. However, contract personnel are subject to all position qualifications and competency requirements.
Competency: 1. Professional Personnel: Individuals must demonstrate their competency, within their orientation and probationary period, according to the orientation checklists developed for each position. In addition, ongoing competency assessments will be performed and by monitoring information regarding performance. Failure to meet the organization ' s competency expectations may result in termination.
Health Requirements: 1. Personnel With Patient Contact: All new personnel who will be in contact with patients and rehires who have not been employed by the organization for over six (6) months, must undergo a physical screening before they are employed or re-employed. In addition, personnel must have TST or show evidence that there is no evidence that there is no active Tuberculosis in the past 12 months (by providing a copy of a negative TST taken within the past 12 months) prior to providing care. Documentation of these tests will be maintained in the personnel health file ....3. The organization retains the option to require annual physical screening of all personnel as required by state or local law or as deemed appropriate by the organization.
A review of agency policy titled " Licensure/Certification/Registration " was conducted on May 8, 2024 at approximately 10:20 am states, Procedure: 1. Personnel must maintain and show proof of licensure, certification, and/or registration as appropriate ....3. A current copy or other proof of licensure, certification, and/or registration will be kept in the personnel file ....5. Any employees who fail to maintain a required license, certification or registration will be subject to suspension or termination.
A review of agency policy titled " Orientation " was conducted on May 8, 2024 at approximately 10:25 am states, Procedure: The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided: 8. A Personnel Orientation Checklist will be completed for all new personnel. New personnel will sign and date when their orientation has been completed. 9. The supervisor will sign and date the checklist when new personnel have completed all the required activities.
A review of agency policy titled " Contracted Service Providers " was conducted on May 8, 2024 at approximately 10:35 am states, Procedure: 1. Documentation of training and professional qualifications may be maintained by TG Circle of Life LLC - Always Best Care or by the contracted organization. If maintained by the contracted organization, verification by TG Circle of Life LLC - Always Best Care will occur at least annually. 2. Documentation will be maintained for at least the following items: A. Successful completion of an approved training course, B. Demonstration of skills competency, C. Completion of organization ' s orientation, D. Current personnel records containing the documentation required by TG Circle of Life LLC - Always Best Care
A review of agency policy titled " Job Descriptions " was conducted on May 8, 2024 at approximately 10:40 am states, Procedure: 2. At the time of hire, each individual will receive and sign a job description specific to his/her position.
A review of agency policy titled " Competency Program " was conducted on May 8, 2024 at approximately 10:45 am states, Procedures: 1. The organization will establish and annually re-evaluate its job specific " Competency Based Orientation Checklist " which reflects duties commonly required in the performance of patient contact positions ....6. After completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process ....
A review of agency policy titled " Categories / Qualifications of Personnel " was conducted on May 8, 2024 at approximately 10:50 am states, Health Requirements: 1. Personnel With Patient Contact: All new personnel who will be in contact with patients and rehires who have not been employed by the organization for over six (6) months, must undergo a physical screening before they are employed or re-employed. In addition, personnel must have TST or show evidence that there is no active Tuberculosis in the past 12 months (by providing a copy of negative TST taken within the past 12 months) prior to providing care. Documentation of these tests will be maintained in the personnel health file ...3. The organization retains the option to require annual physical screening of all personnel as required by state or local law or as deemed appropriate by the organization.
A review of agency policy titled " Performance Evaluations " was conducted on May 8, 2024 at approximately 11:05 am states, Procedure: 1. Performance evaluations will be completed (and dated) on all personnel as follows: B. Annually, based on personnel ' s annual evaluation date ...3. Performance evaluations will be documented on the applicable form, signed by the person completing the evaluation of the employee. The content of the evaluation will be discussed between the individual and the appropriate supervisor. At least annually, clinical personnel must demonstrate proficiencies in the appropriate core competency.
A review of agency policy titled " Competency Based Orientation " was conducted on May 8, 2024 at approximately 11:10 am states, Competency Orientation Skills Checklist Guidelines: 2. Organization personnel rate their knowledge and abilities in the various procedures routinely performed in the course of their jobs on the self-assessment position of the checklists ....4. The method to evaluate each indicator will be documented on the checklist. 5. When the Competency Orientation Skills Checklist is completed, it is reviewed by the preceptor and the Clinical Supervisor. Additional training and education is performed as indicated until competence is demonstrated.
A review of agency policy titled " Competency Assessment " was conducted on May 8, 2024 at approximately 11:15 am states, Procedure: Ongoing Assessments: 1. Competency assessments will be completed at least one (1) time per year. Additional competencies may be required for performance issues, new technology, or other appropriate indications. 2. Using a Competency Skills Performance Checklist developed specifically for each clinical job category, the Clinical Supervisor will evaluate the competence in performing and rendering care according to organization policies and standards of practice. Annual Performance Evaluation: 1. During the annual performance evaluation, personnel ' s competence in performing specified activities will be evaluated.
A review of agency policy titled " Annual Core Competence " was conducted on May 8, 2024 at approximately 11:20 am states, Procedure: 1. Organization personnel will demonstrate proficiency in the performance criteria/skills during the orientation period, and at least annually thereafter as part of the annual performance evaluation process. 2. If organization personnel are not required to perform a specific aspect of care or task as a routine part of their job responsibilities, the performance criteria is simply labeled " Not Applicable " or " N/A " by a qualified evaluator.
A review of agency policy titled " Personnel Record Contents " was conducted on May 8, 2024 at approximately 11:25 am states, Procedure: General Documents: A. Skills and Experience Inventory, B. Signed standards of conduct, C. Verified professional licensure or certification, D. CPR certification (professional personnel), E. Continuing education documentation. New Hire Documents: J. Orientation checklist (completed), K. Initial competency assessment, L. Signed job description ...O. Criminal background check ... Performance Evaluation/ Counseling Documents: A. Performance evaluations (probationary and annual) B. Organization personnel performance observation reports (clinical only), C. Ongoing competency assessments. Contract: D. TB test documentation (Any testing prior to hire and after) ...Additional documentation will be supplied to the facility upon request, including but not limited to: C. Organization personnel performance observation reports (clinical only), D. Ongoing competency assessments, E. Annual TB Screening Results, F. Continuing education documentation. New Hire Documents: D. Orientation checklist (completed) E. Signed job description, G. Criminal background check ...
A review of PF's conducted on May 7, 2023 from approximately 10:00 am to 10:45 am revealed the following:
PF #1, Date of Hire: 2/20/2024, did not contain any documentation of: tuberculosis testing, symptom screening, or risk assessment at hire.
PF#2, Date of Hire: 2/22/2019, did not contain any documentation of: annual competencies for 2021, 2022 and 2023; performance evaluation for 2021, 2022 and 2023 and no documentation of annual TB education for 2021, 2022 and 2023.
PF #4, Date of Hire: 2/28/2024, did not contain any documentation of: orientation documentation and tuberculosis testing, symptom screening, or risk assessment at hire.
PF#5, Date of Hire: 10/26/2020, did not contain any documentation of: Pennsylvania Criminal Background Check was not completed until 10/26/2022; a Child Abuse Clearance; annual competencies for 2021, 2022, and 2023; performance evaluations for 2021, 2022 and 2023 and no documentation of annual TB education for 2021, 2022 and 2023.
PF#6, Date of Hire: 3/2/2022, did not contain any documentation of: a signed job description; orientation documentation, initial competency, annual competencies; performance evaluations; TB testing,symptom screening, or risk assessment at hire and no documentation of an annual TB education.
PF#7, Date of Hire: 7/19/2021, did not not contain any documentation of: a child abuse clearance; annual competencies for 2022 and 2023, performance evaluation for 2022 and 2023 and no documentation of an annual TB education for 2022 and 2023.
An interview with the administrator on May 8, 2024, at approximately 11:30 am confirmed the above findings.
Plan of Correction:A. In accordance to satisfying 28 Pa code 601.21(f) Re Personnel Policies which states 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.
B. The Clinical Manager or designee will obtain all the Personnel Files (PF) for the Home Health Care employees and/or contractors, which that are located in the in the Human Resources department, at the agency's main location at 1172 S. Broad Street, Philadelphia, PA 19146. The PF will then be audited to identify the items that were missing during the recent survey. The missing items will be copied and added to the PF on site at the Home Health Care office, located at 427 W. Girard Ave, Philadelphia, PA 19123.
C. The Clinical Manager and/or Designee will contact the employees and/or contractors that are still missing items, after the PF audits mentioned above. The employees/contractors will complete any training, competencies, or documentation that is needed to ensure their PF is complete and in compliance with the agency's policies, as well as the state, local and federal regulations.
D. The Clinical Manager or Designee will re-train the administrative staff on the items that must be included within each employees personnel record to ensure that the agency is in compliance. In addition, the administrative staff will create a spreadsheet for better oversight and management of the personnel records. The administrative staff will verbalize understanding of the requirements in maintaining the employee personnel records.
E. All corrections and education will be implemented by June 28, 2024.
601.31(a) REQUIREMENT
PATIENT ACCEPTANCE
Name - Component - 00
601.31(a) Patient Acceptance.
Patients are accepted for treatment on
the basis of a reasonable expectation
that the patient's medical, nursing
and social needs can be met adequately
by the agency in the patient's place
of residence. Care follows a written
plan of treatment established and
periodically reviewed by a physician
and care continues under the general
supervision of a physician.
Observations:
Based on a review of agency policy, clinical records (CR), and an interview with the administrator and director of nursing, the agency failed to ensure that an initial assessment was held within 48 hours of the referral for two (2) of seven (7) CRs reviewed, (CR#1 and 6).
Findings include:
A review of agency policy titled " Intake Process " conducted on May 8, 2024, at approximately 10:40 AM, states " Procedure: E. The clinical supervisor will assign personnel and schedule an initial assessment visit. The initial assessment visit will be performed either within 48 hours of the referral, or within 48 hours of a patient ' s return home, or on the start of care date ordered by the physician ... "
A review of agency policy titled " Care/Service Coordination " conducted on May 8, 2024, at approximately 10:45 AM, states " Policy: Each patient will be assigned a case manager upon admission by the clinical director or clinical supervisor. It will be the responsibility of the case manager to facilitate communication about changes in the patient status among the assigned personnel. Procedure: 8. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient's clinical record or interdisciplinary group notes... "
A review of CRs was conducted on May 7, 2024, from approximately 11:00 AM to 2:30 PM and on May 8, 2024, from approximately 9:30 AM to 10:30 AM revealed the following:
CR #1, Start of Care: 11/29/2023. File contained a referral date of 11/17/2023. Initial assessment was documented on 11/29/2023 which is twelve (12) days after the referral date. There is no documentation in the file of a reason for the late start of care.
CR#6, Start of Care: 11/28/2023. File contained a referral date of 11/14/2023. Initial assessment was documented on 11/28/2023, which is fourteen (14) days after the referral date. There is no documentation in the file of a reason for the late start of care.
An interview with the administrator and director of nursing conducted on May 8, 2024, at approximately 11:15 confirmed the above findings.
Plan of Correction:
A. In accordance to satisfy 28 Pa code 601.31 (a) Requirement Patient Acceptance. Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of treatment established and periodically reviewed by a physician and care continues under the general supervision of a physician.
B. The survey identified that services were not started within 48 hours of referral being accepted by the agency. In addition, there was no communication or written documentation noted as to the reason for the delay in the Start of Care assessment.
C. Upon further review by the Clinical Manager, the agency failed to remove the patient's referrals and clinical records from the active census. Both patients identified should have been made "Inactive", as both patients health status prolonged their hospitalizations. The agency should have removed clinical records for both patients and re-entered as a new episode when the patients were discharged to home.
D. The Clinical Manager or Designee will educate all administrative and clinical staff on proper protocol for Patient Intake and Timely Initiation of Care. Both agency Policy 1-005 "Intake Process" and Policy 1-004 "Care/Services Coordination as well as 28 PA code 601.31 (a).
All clinical and administrative staff will verbalize and sign off that they understand and will comply with the guidelines in these polices and regulations regarding Timely Initiation of Care.
E. All corrections and education will be completed by June 28, 2024.
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 agency policy, clinical records (CR), and an interview with the administrator and director of nursing, it was determined to agency failed to maintain an accurate medication list per physician orders for four (4) of seven (7) CR's reviewed, (CR #1, 2, 3, and 7).
Findings include:
A review of agency policy titled "Medication Profile" conducted on May 8, 2024, at approximately 10:30 AM, states "Policy: Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication Profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. Procedure: 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed ...and with the addition of a new medication ... "
A review of agency policy titled " Care Planning Process " conducted on May 8, 2024, at approximately 10:35 AM, states " Policy: A written plan of care will be initiated withing five (5) days of start of care and updated at least every 60 days or as patient ' s condition warrants ...Procedure: 3. Based on the assessment and conclusions, the plan of care will include, but will not be limited to: K. All medications ... "
A review of CR's conducted on May 7, 2024, from approximately 11:00 AM to 2:30 PM and on May 8, 2024, from approximately 9:30 AM to 10:30 AM revealed the following:
CR #1, Start of Care: 11/29/2023; Certification period reviewed: 3/28/2024 through 5/26/2024. Home Health Certification and Plan of Care contained the following medication orders: Ammonium Lactate External 12%, 1 milliliter as needed for rash; Nitroglycerin Sublingual 0.4 milligram, 1 tab sublingual as needed for chest pain, may repeat in 10 minutes, if symptoms persist, call 911; and Wheat Dextrin oral, one as needed for constipation. There is no documentation of where the Ammonium Lactate is to be applied and no frequency documented. There is no maximum dose limit for Nitroglycerin Sublingual. There is no frequency documented for the Wheat Dextrin.
CR #2, Start of Care: 4/2/2024; Certification period reviewed: 4/2/2024 through 5/31/2024. The medication profile contained Folic Acid 1 milligram, one tablet daily started 4/16/2024. There is no documentation of a physician order to add the Folic Acid.
CR#3, Start of Care: 3/22/2024. Certification period reviewed: 3/22/2024 through 5/20/2024. Home Health Certification and Plan of Care contained an order for Amoxicillin Oral 500 milligrams, one cap, two times a day. The medication profile did not contain the Amoxicillin.
CR#7, Start of Care: 3/20/2024. Discharge date: 4/3/2024 Certification period reviewed: 3/20/2024 through 5/18/2024. The medication profile contained Motrin IB Oral 200 milligrams; one to two tabs as needed for moderate pain every six hours started on 3/27/2024. There is no documentation of a physician order to add the Motrin.
An interview with the administrator and director of nursing conducted on May 8, 2024, at approximately 11:15 AM confirmed the above findings.
Plan of Correction:A. In accordance to satisfying 28 Pa Code 601.31(d) Requirement Conformance with Physician's Orders, which states 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.
B. In addition, the agency's Policy 2-005 - Medication Profile states, (1) Patients receiving medications administered by the organization will have a current and accurate medication profile in the clinical record. Medication Profiles will be updated for each change to reflect current medications, new and/or discontinued medications. (2) A drug regime review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and with the addition of a new medication.
C. The survey findings that were identified include missing physicians' orders, no frequency, no maximum dose, and no location for subcutaneous application.
D. The Clinical Manager or Designee will educate the clinical staff on 28 Pa code 601.31 (d) and re-educate the staff on the agency's policies titled "Medication Profile", and "Care Planning Process". All clinical staff will verbalize and sign off that they understand and will comply with the guidelines and polices regarding physicians' orders and medications.
E. The Clinical Manager or Designee will oversee the correction of the four patient records that were identified during the survey.
F. The Clinical Manager or Designee will review all patients records at SOC, discharge, and at least every 60 days for patients that are recertified to home health care to ensure that the polices and regulations are being upheld.
G. All correction and education will be implemented by June 28, 2024.
Initial Comments:
Based on the findings of an onsite unannounced home health agency state re-licensure survey conducted May 7, 2024 through May 8, 2024, Always Best Care, was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
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 a review of agency complaint/incident log, and an interview with the administrator and director of nursing, the agency failed to document reportable events as per the PA Dept. of Health's Event Reporting System (ERS) manual for one (1) incident reviewed, (INC#1).
Findings include:
Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
A review of agency's complaint/incident log conducted on May 7, 2024, at approximately 1:00 PM revealed INC#1 dated 12/23/2023 and written by Physical Therapist (PT), states "I saw patient yesterday at 11:30 AM. Patient reported he fell in the AM when caregiver arrived and attempted to transfer patient out of recliner couch and into wheelchair. Patient states his feet slid forward and caregiver slowly controlled his descent into sit on the floor. Patient states he was not wearing his slip resistant socks with the bumps on the bottom or any shoes and was just wearing regular socks, so it was more slippery and he had no grip on the floor. Patient denies injuries or hitting floor hard because caregiver was present to control fall. No injuries noted upon assessment." There is no documentation to note if caregiver was employee of agency.
The Pennsylvania (PA) Department of Health's Event Reporting System (ERS) was reviewed on 5/6/2024 at 2:00 PM. There was no documentation of any ERS reports filed by agency since inception.
An interview with the administrator and director of nursing conducted on May 8, 2024 at 11:15 AM confirmed the above findings.
Plan of Correction:A. In accordance to satisfying 28 Pa code 51.3 [g], (1-14) Licensure Notification for purpose of subsections (e) and (f), events which seriously compromise quality assurance and patient safety (please refer to the findings to the left).
B. The Clinical Manager, upon further investigation, determined that the caregiver who reported the fall to the Physical Therapist is not an employee of Always best Care Senior Services.
C. The review further identified that the physical therapist should have notified the Clinical Manager, the patient's family or designee, and the medical provider. In addition, the therapist should have educated the patient, family members and or caregivers on best practices of safety measures and transfers to help prevent falls and or occurrences within the patients home environment including but not limited to the use of proper footwear when ambulating.
D. The Clinical Manager or designee will provide all clinical staff with a copy of 28 PA code 51.3 [1-14] regulations including (g),(e),(f), with written and verbal education. All clinicians will sign off on understanding of incident reporting and patient safety.
E. All corrections and education will be implemented by June 28, 2024.
Initial Comments:
Based on the findings of an onsite unannounced home health agency state re-licensure survey conducted May 7, 2024 through May 8, 2024, Always Best Care, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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