QA Investigation Results

Pennsylvania Department of Health
BRIGHTSTAR CARE OF HAPPY VALLEY
Health Inspection Results
BRIGHTSTAR CARE OF HAPPY VALLEY
Health Inspection Results For:


There are  2 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an unannounced, on-site state relicensure survey conducted February 18, 2020 through February 19, 2020, Brightstar Care of Happy Valley, was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.






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 upon review of personnel file (PF), interview with agency owner (EMP# 1), it was determined agency failed to show evidence of job description for one (1) of four (4) PFs reviewed (PF # 1); failed to show orientation for two (2) of four (4) PFs reviewed (PF# 2 and PF# 3); failed to show annual performance evaluations for three (3) of four (4) PFs reviewed. (PF# 1, PF# 2 and PF# 4); failed to show evidence of initial two-step Tuberculosis (TB) screening for one (1) of four (4) PFs reviewed (PF# 2) and failed to show evidence of annual Tuberculosis screening for three (3) of four (4) PFs reviewed. (PF# 1, PF# 2 and PF# 4)

Findings included:

Review of 'Employee Orientation' policy on February 18, 2020 at approximately 1:00 p.m. reads, "Procedure: (1) Each caregiver will receive orientation to the agency's policies, procedures and applicable practices to ensure their understanding prior to patient assignment...(3) Caregivers shall complete an orientation conducted by the Director or Nursing...including, as applicable, the following topics: a. Caregivers' duties and responsibilities according to their training, registration, certification or license;..f. Job assignment and supervision of services..."

Review of 'Personnel' policy on February 18, 2020 at approximately 1:10 p.m. reads, "Procedure:...3. Each position with BrightStar Healthcare will include a job description...The job description/qualifications will be signed by the employee and included in the employee's personnel file upon being hired...4. All direct and contact employees of BrightStar Healthcare shall complete an orientation. Documentation of the orientation shall be signed by the employee, as well as the person giving the orientation, and shall be kept in the employee's personnel file...5. Performance evaluations shall be performed on field staff during the first 90 days of employment and thereafter at least annually...Evaluations shall be maintained in the personnel files for each individual..."

Review of 'Tuberculosis Screening of Health Care Workers Policy (2-Step)' policy on February 18, 2020 at approximately 1:15 p.m. reads, "Procedure: 1. Pre-Placement/Initial TB Screening...Initial baseline TB screening of the HCW (Health Care Worker): Initial baseline TB screening of the HCW: Two-step tuberculin skin testing...2. Annual TB testing and/or Screening...HCWs with a negative baseline will complete the TB Screening Questionnaire annually..."


Review of PFs conducted on February 18, 2020 between 12:00 p.m. and 4:00 p.m. revealed the following:

PF # 1, Date of Hire, (DOH) 2/10/2017: No documentation of providing job description; annual performance evaluation for 2018 and 2019; and no documentation of annual tuberculosis screening for 2018 and 2019

PF # 2, DOH, 7/30/2018: No documentation of providing orientation; annual performance evaluation for 2019; initial two-step TB screening and no documentation of annual tuberculosis screening for 2019

PF # 3, DOH, 12/9/2019: No documentation of providing orientation

PF # 4, DOH, 8/8/2017: No documentation of providing annual performance evaluation for 2018 and 2019 and no documentation of annual tuberculosis screening for 2018 and 2019


Interview with EMP # 1 on February 19, 2020 at approximately 3:30 p.m. confirmed the above policies are current and above findings.










Plan of Correction:

1) All employees audited who are still employed with our organization will have requirements met for personnel files. Including signed Job descriptions, orientation complete materials, documentation on TB screening, annual performance evaluations. For PF#2 this information is not able to be provided as the employee has not been with the organization since January 2020.
2) We will perform an audit for all Home Health employees to ensure their personnel files are correct.
3) We are creating a new audit tool to ensure compliance
4) We are implementing quarterly audits of all employee files with the new tool. The HR director and Administrator will be responsible for implementing and overseeing this.
5) Date of completion 4/19/2020



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 review of agency policy, skilled clinical/Quality Audit tool and interview with agency owner (EMP# 1), it was determined the agency failed to show evidence of continuous Clinical Record Reviews (CRR) quarterly for 2018 and 2019 for one (1) of one (1) CRRs reviewed (CRR # 1)

Findings included:

Review of 'Quaterly Clinical Review and Annual Program Evaluation' policy on February 19, 2020 at approximately 2:15 p.m. reads,"..."Procedure: (1) An interdisciplinary quality assurance/performance improvement (QAPI) committee shall evaluate patient services at least quarterly and a written report of the finding shall be submitted to the Administrator and be available in the agency..."

CRR # 1: No documentation of continuous quarterly CCR report and record reviewed conducted for year of 2018 and 2019. CRR completed in April 2019 and May 2019.

Interview with EMP # 1 on February 19, 2020 at approximately 3:30 p.m. confirmed the above policies are current and above findings.












Plan of Correction:

1) We will go through and do a clinical record review for 2019 records
2) A New audit tool will be developed
3) Quarterly clinical reviews will be implemented and done ongoing starting with January 2020. Minutes will be kept for meetings to have a record of the information discussed.
4) Along with Quaterly clinical reviews, the information will be submitted for review to the annual program evaluation committee. We will audit all clinical files until we have reached 20 ongoing clients, at that point we will randomly audit 10 clinical files per quarter. Nursing supervisor and administrator will be responsible for implementing these changes.
5) Date of completion 4/19/2020



601.31(b) REQUIREMENT
PLAN OF TREATMENT

Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).

If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.

Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.

Observations:


Based on review of agency policy, clinical records (CRs) and interview with agency owner (EMP# 1), it was determined the agency failed to demonstrate the plan of care covered all pertinent diagnoses including but not limited to: types of services needed, frequency of visits, duration, rehabilitation potential, and safety measures to protect against injury for seven (7) of seven (7) CRs reviewed. (CR# 1-CR# 7)

Findings included:

Review of 'Plan of Care' policy on February 19, 2020 at approximately 2:15 p.m. reads,"..."Procedure: 1. The plan of care shall be developed in consultation with the agency staff and shall cover: I. Pertinent diagosis including mental status, II. Types of services and equipment required III. Frequency of visits...V. Rehabilitation potential...X. Safety measures to protect against injury...XII. Other appropriate items...3. The total plan of treatment shall be reviewed by the attending physician and home health agency personnel as often as the severity of the patient' s condition requires, but at least once every 60 days...4. Agency personnel shall promptly alert the physician to changes that suggest a need to alter the plan of treatment..."

Review of CRs conducted on February 19, 2020 between approximately 10:30 a.m. to 3:00 p.m. revealed the following:

CR# 1, Start of Care (SOC), 6/5/2019: Patient is a 74 year old female. Certification period is not established within the Plan of Care (POC). Diagnosis listed: Arthritis, Breast Cancer, high BP (blood pressure), nerve pain and wheeze.
Medications listed include: Simvastatin 10 mg (milligram) (medication used to treat high cholesterol). No diagnosis of high cholesterol documentated within POC. No documentation of type of services needed (aide or skilled), frequencies, duration, rehabilitation potential, safety measures.
Review of 'Skilled Nursing Visit Notes" from dates of 8/6/2019 through 2/14/2020.
'Primary Diagnosis' listed: Dementia from dates of 8/6/2019 through 2/14/2020. No diagnosis of Dementia listed on POC.
On 8/6/2019, 'Primary Diagnosis' listed: MDD (Major Depressive Disorder), dementia, seizure disorder. No diagnosis of MDD, dementia or seizure disorder listed on POC. "Safety precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 8/20/2019, "Safety precautions followed" included: Seizure. No diagnosis of seizure listed on POC.
On 8/27/2019, 'Primary Diagnosis' listed: dementia, seizure disorder. No diagnosis of dementia or seizure disorder listed on POC. "Safety precautions followed" included: seizure.
On 9/19/2019, 'Primary Diagnosis' listed: dementia, seizure disorder. No diagnosis of MDD, dementia or seizure disorder listed on POC.
On 9/24/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia disorder listed on POC. "Safety precautions followed" included: seizure. No diagnosis of seizure listed on POC.
On 10/8/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia disorder listed on POC. "Safety precautions followed" included: diabetic and seizure. No diagnosis of diabetes and seizures listed on POC.
On 11/12/2019, 'Primary Diagnosis' listed: dementia and anxiety/depression. No diagnosis of dementia or anxiety/depression listed on POC. "Safety precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 11/19/2019, 'Primary Diagnosis' listed: mild dementia. No diagnosis of mild dementia listed on POC. "Safety precautions followed" included: diabetic and seizure. No diagnosis of diabetes and seizure listed on POC.
On 11/26/2019, 'Primary Diagnosis' listed: dementia and anxiety. No diagnosis of dementia and anxiety listed on POC.
On 12/17/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC. "Safety precautions followed" included: seizure. No diagnosis of seizure listed on POC.
On 12/20/2019, 'Primary Diagnosis' listed: mild dementia. No diagnosis of mild dementia listed on POC.
On 12/31/2019, 'Primary Diagnosis' listed: dementia, mild. No diagnosis of mild dementia listed on POC.


CR# 2, SOC, 2/1/2019: Patient is a 65 year old female. Certification period is not established within the Plan of Care (POC). Diagnosis listed: hx (history) of stroke. Type of diet: diabetic. Diabetes not listed as other pertinent diagnosis in POC.
Medications listed include: Accu-Chek Softclix Lancets (assist in testing blood sugar levels), atorvastatin 80 mg (high cholesterol medication), Nexium 40 mg (gastric reflux medication), Effexor XR 75 mg (Antidepressant medication), Albuterol Sulfate (Proair) inhaler) (bronchodilator medication used to treat breathing problems), Requip 0.5mg (Restless leg syndrome medication), Metformin ER 500 mg (diabetic medication). No diagnosis documentated within POC corresponding medication list. No documentation of type of services needed (aide or skilled), frequencies, duration, rehabilitation potential, safety measures.
Review of 'Skilled Nursing Visit Notes" from dates of 3/8/2019 through 2/14/2020.
On 3/8/2019, 'Primary Diagnosis' listed: Recovery from severe case of Influenza and a fall. Had a stroke a couple of yrs (years) ago and diabetic Type II. No diagnosis of Influenza, fall and Diabetic Type II listed on POC.
On 3/15/2019, 'Primary Diagnosis' listed: Dementia/Diabetes/Thyroid Disease. No diagnosis of Dementia, Diabetes and Thyroid Disease listed on POC. "Safety precautions followed" included: diabetic.
On 5/7/2019, 'Primary Diagnosis' listed: Dementia, Diabetes. No diagnosis of Dementia and Diabetes on POC.
On 5/21/2019, 'Primary Diagnosis' listed: Dementia. No diagnosis of Dementia listed on POC.
On 5/30/2019, 'Primary Diagnosis' listed: Dementia. No diagnosis of Dementia listed on POC.
On 8/9/2019, 'Primary Diagnosis' listed: Dementia, diabetes, chronic pain. No diagnosis of Dementia, Diabetes and chronic pain listed on POC. "Safety precautions followed" included: diabetic.
On 8/23/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of Dementia listed on POC. "Safety precautions followed" included: diabetic. No diagnosis of Diabetes listed on the POC.
On 9/6/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of Dementia listed on POC. "Safety precautions followed" included: diabetic. No diagnosis of Diabetes listed on the POC.
On 9/20/2019, 'Primary Diagnosis' listed: med non-compliance, dementia. No diagnosis of med non-compliance and Dementia listed on POC. "Safety precautions followed" included: diabetic.
On 10/10/2019, 'Primary Diagnosis' listed: dementia, anxiety, diabetes. No diagnosis of Dementia, anxiety, and diabetes listed on POC.
On 11/14/2019, 'Primary Diagnosis' listed: dementia, diabetes. No diagnosis of Dementia and diabetes listed on POC.
On 11/19/2019, 'Primary Diagnosis' listed: dementia r/t (related to) stroke. No diagnosis of Dementia listed on POC. "Safety precautions followed" included: diabetic. No diagnosis of Diabetes listed on the POC.
On 11/29/2019, 'Primary Diagnosis' listed: diabetes. No diagnosis of diabetes listed on POC.
On 12/10/2019, 'Primary Diagnosis' listed: arthritis, dementia. No diagnosis of arthritis, dementia listed on POC.
On 12/13/2019, 'Primary Diagnosis' listed: dementia, diabetes. No diagnosis of dementia and diabetes listed on POC. "Safety precautions followed" included: diabetic and bleeding. No diagnosis of Diabetes and bleeding listed on the POC.
On 1/23/2019, 'Primary Diagnosis' listed: dementia and diabetes. No diagnosis of dementia and diabetes listed on POC.
On 1/30/2019, 'Primary Diagnosis' listed: dementia and diabetes. No diagnosis of dementia and diabetes listed on POC.


CR# 3, SOC, 1/28/2019: Patient is a 91 year old female. Certification period is not established within the Plan of Care (POC). Diagnosis listed: Alzheimers, Heart Disease.
No documentation of type of services needed (aide or skilled), frequencies, duration, any equipment needed, nutritional requirements, functional limitations, activities permitted, rehabilitation potential, safety measures.
Review of 'Skilled Nursing Visit Notes" from dates of 4/10/2019 through 2/14/2020.
On 8/13/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 9/3/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 9/17/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 10/22/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 11/5/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 11/19/2019, 'Primary Diagnosis' listed: dementia and hypertension. No diagnosis of dementia and hypertension listed on POC.
On 12/3/2019, 'Primary Diagnosis' listed: dementia, B12 def (deficiency). No diagnosis of dementia and B12 deficiency listed on POC.
On 1/23/2020, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 2/14/2020, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.

CR# 4, SOC, 12/13/2018: Patient is a 66 year old female. Certification period is not established within the Plan of Care (POC). No principal diagnosis documented. No other pertinent diagnoses documented. No diagnoses documentated within POC corresponding to medication list. No documentation of type of services needed (aide or skilled), frequencies, duration, equipment needed, nutritional requirements, rehabilitation potential, safety measures.
Review of 'Skilled Nursing Visit Notes" from dates of 1/10/2019 through 2/8/2020.
On 12/10/2019, 'Primary Diagnosis' listed: BPD (Borderline personality disorder) . No diagnosis of Borderline personality disorder listed on POC.
On 12/17/2019, 'Primary Diagnosis' listed: Borderline personality disorder. No diagnosis of Borderline personality disorder listed on POC.
On 12/20/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of Borderline personality disorder listed on POC.
On 12/21/2019, 'Primary Diagnosis' listed: depression, anxiety. No diagnosis of depression and anxiety listed on POC.
On 1/17/2019, 'Primary Diagnosis' listed: Borderline personality disorder. No diagnosis of Borderline personality disorder listed on POC. "Gastrointestinal/Nutritional Diet" listed: Diabetic. No diagnosis of diabetes listed on POC.
On 1/24/2019, 'Primary Diagnosis' listed: BPD and depression. No diagnosis of Borderline personality disorder and depression listed on POC.
On 1/31/2019, 'Primary Diagnosis' listed: Borderline personality disorder. No diagnosis of Borderline personality disorder listed on POC.
On 2/21/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of Borderline personality disorder listed on POC.
On 2/28/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of Borderline personality disorder listed on POC.
On 4/10/2019, 'Primary Diagnosis' listed: BPD and anxiety. No diagnosis of Borderline personality disorder and anxiety listed on POC.
On 4/18/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of Borderline personality disorder listed on POC.
On 4/25/2019, 'Primary Diagnosis' listed: Diabetes, BPD and chronic pain. No diagnosis of diabetes, Borderline personality disorder and chronic pain listed on POC. "Safety precautions followed" included: diabetic.
On 5/16/2019, 'Primary Diagnosis' listed: BPD, anxiety and diabetes. No diagnosis of Borderline personality disorder, anxiety and diabetes listed on POC.
On 5/21/2019, 'Primary Diagnosis' listed: BPD, depression/anxiety. No diagnosis of Borderline personality disorder, depression and anxiety listed on POC. "Safety precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 5/23/2019, 'Primary Diagnosis' listed: BPD and diabetes. No diagnosis of Borderline personality disorder and diabetes listed on POC.
On 5/30/2019, 'Primary Diagnosis' listed: BPD, anxiety and diabetes. No diagnosis of Borderline personality disorder, anxiety and diabetes listed on POC.
On 6/6/2019, 'Primary Diagnosis' listed: depression, anxiety and diabetes. No diagnosis of depression, anxiety and diabetes listed on POC.
On 6/13/2019, 'Primary Diagnosis' listed: depression, anxiety, BPD and diabetes. No diagnosis of depression, anxiety, BPD and diabetes listed on POC.
On 8/6/2019, 'Primary Diagnosis' listed: diabetes and depression. No diagnosis of diabetes and depression listed on POC.
On 8/13/2019, 'Primary Diagnosis' listed: depression and diabetes. No diagnosis of depression and diabetes listed on POC.
On 8/20/2019, 'Primary Diagnosis' listed: depression and anxiety. No diagnosis of depression and anxiety listed on POC.
On 8/27/2019, 'Primary Diagnosis' listed: depression and anxiety. No diagnosis of depression and anxiety listed on POC. Safety Precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 9/4/2019, Safety Precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 9/10/2019, 'Primary Diagnosis' listed: depression and anxiety. No diagnosis of depression and anxiety listed on POC.
On 9/17/2019, 'Primary Diagnosis' listed: depression. No diagnosis of depression listed on POC.
On 9/19/2019, 'Primary Diagnosis' listed: depression, personality disorder and anxiety. No diagnosis of depression, personality disorder and anxiety listed on POC.
On 10/22/2019, 'Primary Diagnosis' listed: BPD, diabetes, depression with anxiety. No diagnosis of BPD, diabetes, depression with anxiety listed on POC.
On 10/29/2019, 'Primary Diagnosis' listed: BPD, depression and chronic pain. No diagnosis of BPD, depression and chronic pain listed on POC.
On 11/5/2019, 'Primary Diagnosis' listed: BPD, depression, anxiety and chronic pain. No diagnosis of BPD, depression, anxiety and chronic pain listed on POC.
On 11/12/2019, 'Primary Diagnosis' listed: depression and diabetes. No diagnosis of depression and diabetes listed on POC.
On 11/26/2019, 'Primary Diagnosis' listed: diabetes, depression and anxiety. No diagnosis of diabetes, depression and anxiety listed on POC. Safety Precautions followed" included: diabetic.
On 12/3/2019, 'Primary Diagnosis' listed: borderline personality disorder. No diagnosis of borderline personality disorder listed on POC.
On 12/10/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of BPD listed on POC.
On 12/17/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of BPD listed on POC.
On 12/20/2019, 'Primary Diagnosis' listed: BPD. No diagnosis of BPD listed on POC. Safety Precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 12/31/2019, 'Primary Diagnosis' listed: depression and anxiety. No diagnosis of depression and anxiety listed on POC. Safety Precautions followed" included: diabetic. No diagnosis of diabetes listed on POC.
On 2/3/2020, 'Primary Diagnosis' listed: depression/anxiety and BPD. No diagnosis of depression/anxiety and BPD listed on POC.

CR# 5, SOC, 1/17/2019: Patient is a 61 year old female. Certification period is not established within the Plan of Care (POC). Diagnosis listed: Bilateral edema/diabetes.
No documentation of type of services needed (aide or skilled), frequencies, duration, nutritional requirements, rehabilitation potential, safety measures.
Review of 'Skilled Nursing Visit Notes" from dates of 2/5/2019 through 2/14/2020.
On 2/12/2019, 'Primary Diagnosis' listed: severe venous insufficiency. No diagnosis of severe venous insufficiency listed on POC.
On 2/13/2019, 'Primary Diagnosis' listed: severe venous disease. No diagnosis of severe venous disease listed on POC.
On 2/14/2019, 'Primary Diagnosis' listed: venous insufficiency. No diagnosis of venous insufficiency listed on POC.
On 3/8/2019, 'Primary Diagnosis' listed: lymphedema, venous insuff (insufficiency). No diagnosis of lymphedema, venous insuff listed on POC.
On 8/27/2019, 'Primary Diagnosis' listed: seizure dx (diagnosis), sleep apnea and dementia. No diagnosis of seizure dx (diagnosis), sleep apnea and dementia listed on POC.
On 11/12/2019, 'Primary Diagnosis' listed: CHF (Congestive Heart Failure) and dementia. No diagnosis of CHF and dementia listed on POC.

CR# 6, SOC, 12/28/2018: Patient is a 92 year old female. Certification period is not established within the Plan of Care (POC). Diagnosis listed: Diabetes, High blood pressure and anxiety.
No documentation of type of services needed (aide or skilled), frequencies, duration, nutritional requirements, rehabilitation potential, safety measures.
Review of 'Skilled Nursing Visit Notes" from dates of 1/29/2019 through 1/7/2020.
On 1/29/2019, 'Primary Diagnosis' listed: hypothyroidism. No diagnosis of hypothyroidism listed on POC.
On 3/5/2019, 'Primary Diagnosis' listed: depression. No diagnosis of depression listed on POC.
On 3/12/2019, 'Primary Diagnosis' listed: mild dementia. No diagnosis of mild dementia listed on POC.
On 4/23/2019, 'Primary Diagnosis' listed: mild dementia. No diagnosis of mild dementia listed on POC.
On 5/7/2019, 'Primary Diagnosis' listed: mild dementia. No diagnosis of mild dementia listed on POC.
On 5/21/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 6/4/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 8/6/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 8/13/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 9/3/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 9/6/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 9/10/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.
On 9/17/2019, 'Primary Diagnosis' listed: dementia. No diagnosis of dementia listed on POC.

CR# 7, SOC, 4/2/2019: Patient is a 78 year old female. Certification period is not established within the Plan of Care (POC). Diagnosis listed: Alzheimers, Diabetes, Severe knee pain and Dementia.
No documentation of type of services needed (aide or skilled), frequencies, duration, equipment necessary, nutritional requirements, rehabilitation potential, safety measures.


Interview with EMP # 1 on February 19, 2020 at approximately 3:30 p.m. confirmed the above policies are current and above findings.
















Plan of Correction:

1) We will update and correct all Plan's of treatment that were audited to ensure completion and thoroughness of the plan and to ensure compliance with the rules and regulations. All corrected or new plans of care will be signed off by the attending physician.
2) We will go through and audit all current clients and update their plans of care and have them signed by the attending physician
3) We are changing our plan of care form to include all necessary information for the physician to be signing off for care. Referrals made to us from the OLTL will be required to have the attending physician information prior to going to perform the initial nursing assessment and creation of the plan of care. This will ensure the plan of care being signed at the start of care. We have changed our policy regarding the certification period to reflect the authorization from OLTL.
4) Quarterly clinical reviews will be used to make sure accuracy, completion, and thoroughness of the plan of care, as well as monitoring that nursing notes are reflective of the plan of care. This will be overseen by the nursing supervisor and the administrator.
5) Date of Completion 4/19/2020



601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT

Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment

Observations:


Based on review of agency policy, clinical records (CRs) and interview with agency owner (EMP# 1), it was determined the agency failed to ensure the total plan of treatment is reviewed by the attending physician at least every 60 days for six (6) of seven (7) CRs reviewed. (CR# 2-CF# 7)

Findings included:

Review of 'Plan of Care' policy on February 19, 2020 at approximately 2:15 p.m. reads,"..."Procedure:...3. The total plan of treatment shall be reviewed by the attending physician and home health agency personnel as often as the severity of the patient's condition requires, but at least once every 60 days...4. Agency personnel shall promptly alert the physician to changes that suggest a need to alter the plan of treatment....5. Agency staff shall check medications at the start of care/changes in the regime to identify any issues, and report problems to the physician promptly..."

Review of CRs conducted on February 19, 2020 between approximately 10:30 a.m. to 3:00 p.m. revealed the following:

CR# 2, SOC, 2/1/2019: Patient is a 65 year old female. Certification period is not established within the Plan of Care (POC). No documentation provided of a signed sixty day summary to the physician for date ranges of 8/1/2019 through 10/1/2019 and 10/1/2019 through 12/1/2019. Sixty day summary dated 5/3/2019 was presented unsigned.

CR# 3, SOC, 1/28/2019: Patient is a 91 year old female. Certification period is not established within the Plan of Care (POC). No documentation provided of a signed sixty day summary to the physician for date ranges of 3/28/2019 through 5/28/2019, 5/28/2019 through 7/28/2019 and 11/28/2019 through 1/28/2020.

CR# 4, SOC, 12/13/2018: Patient is a 66 year old female. Certification period is not established within the Plan of Care (POC). No documentation provided of a signed sixty day summary to the physician for date ranges of 4/13/2019 through 6/13/2019.

CR# 5, SOC, 1/17/2019: Patient is a 61 year old female. Certification period is not established within the Plan of Care (POC). No documentation provided of a signed sixty day summary to the physician for date ranges of 5/17/2019 through 7/17/2019, 11/17/2019 through 1/17/2019, 1/17/2019 through 3/17/2019, 3/17/2019 through 5/17/2019, 5/17/2019 through 7/17/2019, 7/17/2019 through 9/17/2019, 9/17/2019 through 11/17/2019 and 11/17/2019 through 1/17/2020.

CR# 6, SOC, 12/28/2018: Patient is a 92 year old female. Certification period is not established within the Plan of Care (POC). No documentation provided of a signed sixty day summary to the physician for date ranges of 6/28/2019 through 8/28/2019 and 10/28/2019 through 12/28/2019.

CR# 7, SOC, 4/2/2019: Patient is a 78 year old female. Certification period is not established within the Plan of Care (POC). No documentation provided of a signed sixty day summary to the physician for date ranges of 8/2/2019 through 10/2/2019. Sixty day summary dated 8/6/2019 was presented unsigned.

Interview with EMP # 1 on February 19, 2020 at approximately 3:30 p.m. confirmed the above policies are current and above findings.





















Plan of Correction:

1) All identified deficient clients are being reevaluated and correcting their Plans of care, which will establish new 60 day periods.
2) We will audit all current clients charts for compliance.
3) We are removing our old 60 day reassessment form and updating our overall plan of care form for clients that will also include the 60 day reassessment.
4) We are doing quarterly clinical reviews that will also review completion and compliance of 60 day reassessments. The nursing supervisor and administrator will provide oversight for implementing these changes.
5) Completion date 4/19/2020



Initial Comments:


Based upon an unannounced, on-site state relicensure survey conducted February 18, 2020 through February 19, 2020, Brightstar Care of Happy Valley, 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 upon an unannounced, on-site state relicensure survey conducted February 18, 2020 through February 19, 2020, Brightstar Care of Happy Valley, was found to be in compliance with the requirements of 35 P. S.448.809 (b).




Plan of Correction: