Initial Comments:
Based on the findings of an unannounced on-site state licensure survey completed February 20, 2024, Carepine Home Health , Llc. 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 a review of agency policy, a review of employee files, and an interview with the agency Office Manager, the agency failed to ensure employee performance evaluations were conducted for four (4) of four (4) employee file (EF) reviewed (EF#1- EF#4).
Findings:
Agency policy was reviewed on February 20, 2024 at approximately 11:30 a.m. HR-Policy 1-014.1 'Performance Evaluations' 'Procedure' (1) states "Performance evaluations will be completed on all employees as follows: (A.) Annually, ....." (3) states "Performance evaluations will be documented on the applicable form and discussed between the individual and the appropriate supervisor. ....."
A review of EFs was completed on February 20, 2024 at approximately 10:00 a.m. The employees date of hire (DOH) is listed below.
EF#1 DOH 09/04/17: No documentation provided of employee performance evaluations, per agency policy, for 2022 and 2023.
EF#2 DOH 03/18/19: No documentation provided of employee performance evaluations, per agency policy, for 2022 and 2023.
EF#3 DOH 06/03/19: No documentation provided of employee performance evaluations, per agency policy, for 2023.
EF#4 DOH 05/15/17: No documentation provided of employee performance evaluations, per agency policy, for 2022 and 2023.
An interview conducted with agency Office Manager on February 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:The office manager or designee will review all employee files at the beginning of every month but no later than the 15th of every month to confirm compliance with the following requirements:
The office manager or designee has completed each employee's performance evaluation for the current year or within the last 12 months. If a performance still needs to be completed, the office manager will schedule one within 14 days of discovering non-compliance. The office manager or designee will follow up seven days after the scheduled date to confirm the completion of the annual performance.
The office manager has configured the EMR system to alert the office at least 90 days before a performance evaluation is due. She has also configured the system to prevent the scheduler from scheduling any employee who has yet to receive an annual performance evaluation for the current year or within the last 12 months.
The office manager or designee will also complete the 2023 performance evaluation for employees EF# 1, EF# 2, EF# 3, and EF# 4 by March 12th, 2024.
The office manager will audit all employee charts to ensure compliance with this requirement by March 15th, 2024.
The office manager will monitor and audit 25% of all employee files every quarter to ensure that a performance evaluation has been completed for each employee
601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES
Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.
Observations:
Based on a review of agency policy, review of clinical records, and an interview with the agency Office Manager, the agency failed to ensure agency personnel maintains liason to assure provided services compliment one another for two (2) of two (2) clinical records (CR) reviewed (CR#3, CR#5).
Findings:
Agency policy was reviewed on February 20, 2024 at approximately 11:30 a.m. Policy 2-025.1 'Care Coordination' section (2) 'Policy' states "....... The clinicians will be responsible for facilitating communications about changes in the patients status among the assigned personnel. Written evidence of care coordination will be recorded during the case conference (if applicable) and repeated in skilled nursing visit reports in the patients clinical record. "
A review of CRs was completed on February 20, 2024 between approximately 12:00 p.m. The patients start of care (SOC) is listed below.
CR#3 SOC 01/24/24: Patients certification of the Plan of Care for the period of 01/24/24 - 03/23/24 reviewed. 'Frequency/Duration of visits' include orders for skilled nursing, physical therapy, and occupational therapy. No documentation provided of agency personnel maintaining liason (clinical record or minutes of case conferences) to assure their efforts effectively complement one another and support the objectives outlined in the plan of treatment.
CR#5 SOC 08/08/23: Patients current recertification period is 01/31/24-03/30/24. Patients certification of the Plan of Care for the period of 08/08/23-10/06/23 reviewed. 'Frequency/Duration of visits' include orders for skilled nursing, physical therapy, and occupational therapy. No documentation provided of agency personnel maintaining liason (clinical record or minutes of case conferences) to assure their efforts effectively complement one another and support the objectives outlined in the plan of treatment.
An interview conducted with agency Office Manager on February 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:QA or designee will confirm that all personnel maintain liaison to assure their efforts effectively complement one another and support the objectives outlined in the plan of treatment. All changes in the patient's status will be documented by the clinician, patient liaison or intake coordinator within 24 hours of the change.
The EMR system will be configured to have case conference alerts on a daily basis.
QA will retrain all clinicians when and where to place the case conference notes.
On Weekly basis, QA will review that case conferences are entered at SOC, Recert, and Discharge. If no notes are entered, QA will bring clinician back into office and retrain within 72 hours of discovery of the incident.
QA will perform quarterly samples of case conference notes to ensure all personnel are compliant.
601.22(d) REQUIREMENT
CLINICAL RECORD REVIEW
Name - Component - 00
601.22(d) Clinical Record Review. At
least quarterly, appropriate health
professionals, representing at least
the scope of the program, review a
sample of both active and closed
clinical records to assure that
established policies are followed in
providing services (direct as well as
services under arrangement). There is
a continuing review of clinical
records for each 60-day period that a
patient receives home health services
to determine adequacy of the plan of
treatment and appropriateness of
continuation of care.
Observations:
Based on a review of agency policy, review of clinical records, and an interview with the agency Office Manager, the agency failed to ensure clinical record review was conducted at
least quarterly by appropriate health care professionals, for four (4) of four (4) clinical record quarterly reviews (CRQR) reviewed (CRQR#1- #4).
Findings Include:
Agency policy was reviewed on February 20, 2024 at approximately 11:30 a.m. 'Quality Management Policy' 'Policy' states ".......Clinical records and care plans will be reviewed on a quarterly basis ...." 'Procedure' 'Quarterly Review' section (3) states "Each professional discipline will participate in review of clinical records for its service."
A review of CRQRs was completed on February 20, 2024 between approximately 12:00 p.m.
CRQR#1: Documentation provided of 'Quarterly Clinical Record Review', "1st Quarter Summary 2023. Carepine Home Health Clinical Record Review Committee held its first quarterly record review meeting on April 7, 2023. The following members were present in the meeting: (Chief Executive Officer) and (Office Manager). Charts reviewed: The Clinical Records Committee randomly sampled and reviewed records, representing admissions between 1/1/23 to 3/31/23. Sampling criteria: The records included active admissions, discharges, various diagnosis, and all disciplines. ...." (Note: Neither the Chief Executive Office nor the Office Manager are health professionals, representing the scope of the program.)
No documentation provided of appropriate health professionals, representing at least the scope of the program, reviewing the clinical records.
CRQR#2: Documentation provided of 'Quarterly Clinical Record Review', "2nd Quarter Summary 2023. Carepine Home Health Clinical Record Review Committee held its first quarterly record review meeting on July 14, 2023. In attendance were: The following members were present in the meeting: (Chief Executive Officer) and (Office Manager). Charts reviewed: The Clinical Records Committee randomly sampled and reviewed records, representing admissions between 4/1/23 to 6/30/23. Sampling criteria: The records included active admissions, discharges, various diagnosis, and all disciplines. ...." (Note: Neither the Chief Executive Office nor the Office Manager are health professionals, representing the scope of the program.)
No documentation provided of appropriate health professionals, representing at least the scope of the program, reviewing the clinical records.
CRQR#3: Documentation provided of 'Quarterly Clinical Record Review', "3rd Quarter Summary 2023. On October 13, 2023, a meeting of the Carepine Home Health Clinical Record Review Committee was held. In attendance were: (Chief Executive Officer) and (Office Manager). Charts reviewed: The Clinical Records Committee randomly sampled and reviewed records, representing admissions between 7/1/23 to 9/30/23. Sampling criteria: The records included active admissions,discharges,various diagnosis, and all disciplines. ...." (Note: Neither the Chief Executive Office nor the Office Manager are health professionals, representing the scope of the program.)
No documentation provided of appropriate health professionals, representing at least the scope of the program, reviewing the clinical records.
CRQR#4: Documentation provided of 'Quarterly Clinical Record Review', "4th Quarter Summary 2023. On January 12, 2024, a meeting of the Carepine Home Health Clinical Record Review Committee was held. In attendance were: (Chief Executive Officer) and (Office Manager). Charts reviewed: The Clinical Records Committee randomly sampled and reviewed records, representing 50% of the admissions between 10/1/23 to 12/31/23.
Sampling criteria: The records included active admissions,discharges,various diagnosis, and all disciplines. ...." (Note: Neither the Chief Executive Office nor the Office Manager are health professionals, representing the scope of the program.)
No documentation provided of appropriate health professionals, representing at least the scope of the program, reviewing the clinical records.
An interview conducted with agency Office Manager on February 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:At the end of each quarter, QA will follow up that the quarterly reviews are conducted by appropriate healthcare professionals. Specifically, nursing and therapy supervisors or designee will participate in quarterly reviews.
QA will schedule a meeting every 90 days with appropriate health professionals to assure that the records being sampled are thoroughly reviewed in all aspects of care. QA will then report all findings during the review within 48 hours of finding.
At the end of every quarter, the office manager will follow up with QA to ensure quarterly reviews are conducted by appropriate healthcare professionals and will retrain, if need be, to ensure agency is in compliance with policy.
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, a review of clinical records, and an interview with the agency Office Manager, the agency failed to obtain a physician signature on verbal orders within thirty (30) days on one (1) of seven (7) clinical records (CR) reviewed (CR#7).
Findings include:
Agency policy for obtaining the physicians signature requested on February 20, 2024 at approximately 11:30 a.m. No specific policy provided.
Pennsylvania 'Act of June 30, 2022, P.L. 391, No. 30' "Health Care Facilities Act' is amended to read : " .... (4) "Within 30 days of issuance, an order of home health care services must be signed and dated by a physician, nurse practitioner, or physician assistant."
A review of CRs was completed on February 20, 2024 between approximately 12:00 p.m. The patients start of care (SOC) is listed below.
CR#7 SOC 09/07/23: Verbal physician's order taken by a registered nurse on 09/07/23. The physician's countersignature was obtained on 10/19/23 (43 days).
An interview conducted with agency Office Manager on February 20, 2024 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:QA will retrain the Patient Liaison or designee to ensure that all orders sent to the physician are received within 30 days of order approval. QA will also retrain the Intake Coordinator to take extra precautions to ensure that she enters physician information correctly in the EMR system.
Every 48 hours, the Patient Liaison will contact all physicians with outstanding unsigned orders to obtain order signatures and confirm that all physician contact information, e.g., the mailing address, fax number, etc., is accurate.
Daily, the QA will run a report of all orders sent that day and provide the patient liaison with that information to ensure all orders are recorded with the appropriate physician's signature.
The Physician Participation in Plan of Care, policy # 2-019.1, was updated on 3/1/2024 as follows: "The attending Physician will certify the need for home health services by signing the plan of care/treatment within thirty days of the start of care unless otherwise specified by applicable state law and regulation."
Initial Comments:
Based on the findings of an unannounced on-site state licensure survey completed February 20, 2024, Carepine Home Health , 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 on-site state licensure survey completed February 20, 2024, Carepine Home Health , Llc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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