Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted March 8, 2022 and March 9, 2022, Weallcare 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:
601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS
Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.
Observations:
Based on a review of personnel files (PF), the Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021; agency policy; and an interview with the administrator, the agency failed to provide documentation employees were either vaccinated against COVID-19 or received testing as required for three (3) of five (5) PF's, (PF #2, 4, and 5).
Findings include:
Philadelphia Department of Public Health, Division of COVID-19 Containment Health Alert Dated 10/14/2021, states "Exemptions: An individual may not simply opt out of vaccination. They must submit a medical or religious exemption to the Healthcare Institution where such individual works according to the policies set by the institution. The Institution will determine if an exemption applies.
Healthcare Institutions and organizations that are granting exemptions must create appropriate exemption policies to implement this regulation. Institutions may establish stricter vaccination policies for their workers, contractors, and volunteers that exceed the requirements of the Vaccine Mandate Regulation, to the extent
otherwise permitted by applicable law.
A Healthcare Worker or Healthcare Institution Worker who is granted an exemption must strictly follow the applicable accommodation, including documenting their participation in the accommodation process that their employer or institution has agreed upon. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals, exemptions requested and granted, and participation in accommodations granted. Records must be made available to PDPH upon request.
Self-employed Healthcare Workers must carefully document the need for exemption and ongoing compliance with routine testing as set forth below under " Accommodations for Exceptions. "
Medical
The Healthcare Worker or Healthcare Institution Worker may request an exemption by submitting a certification from a licensed healthcare provider to the appropriate Healthcare Institution. Medical exemptions must include a statement signed by a licensed healthcare provider that states the exemption applies to the specific individual submitting the certification because the COVID-19 vaccine is medically contraindicated for the individual. The certification must also be signed by the Healthcare Worker or Healthcare Institution Worker. For the purposes of the Vaccine Mandate Regulation a licensed healthcare provider means a physician, nurse practitioner, or physician assistant licensed by an authorized state licensing board.
Religious
The Healthcare Worker or Healthcare Institution Worker may request an exemption by submitting a signed statement in writing that the individual has a sincerely held religious belief that prevents them from receiving the
COVID-19 vaccination. An institution may request the worker explain in the certification why the worker ' s religious belief prevents them receiving the COVID-19 vaccine. Philosophical or moral exemptions are not permitted.
Accommodations for Exemptions
Healthcare Institutions must instruct exempted workers to comply with, and such workers must comply with, one of the following options for accommodation:
1. Routine Testing: Exempt individuals must be tested by a PCR test or an antigen test for COVID-19 at least twice (2x) per week. The two tests should be spread out appropriately over the week, but there is not a required time interval to account for varying schedules. If the individual ' s test is within 72 hours of their work shifts for the week, one test may suffice.
2. Virtual accommodation: If possible, the Healthcare Institution can create a fully virtual option for the individual."
A review of agency policy titled "Employee Vaccination Policy" on March 9, 2022 at approximately 10:00 am states, "Policy: In compliance with the executive order mandated by President Biden, every health care employee must either be vaccinated or tested for COVID-19 with a negative result. Per this notice all current employees must provide either proof of vaccination or proof of a negative COVID-19 test taken within a 72-hour period. PROCEDURE: 1. All current employees must provide proof of vaccination or proof of a negative COVID-19 test results within 30 days of this notice...3. If current employees fail to either provide required documenation or contact the agency for assistance within the specified time frame, they WILL NOT be permitted to continue their scheduled shift as per President Biden's executive order. 4. All newly hired employees must provide proof of vaccination or a negative COVID-19 test result at time of hire. 5. If an any case an employee chooses to opt out of being vaccinated, he or she must provide weekly negative COVID-19 test results to the agency to remain on their scheduled shift..."
A review of PF's was conducted on March 8, 2022, from approximately 2:00 pm to 3:00 pm.
PF #2, Date of Hire: 10/28/2020, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #4, Date of Hire: 11/11/19, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
PF #5, Date of Hire: 2/19/18, did not contain any documentation that the employee received COVID-19 vaccination(s) and did not contain any documentation of exemption or documentation of twice weekly testing.
An interview with the administrator conducted on March 9, 2022, at approximately 11:30 am confirmed the above findings.
Plan of Correction:The Administrator will ensure that all staff has proof of Covid Vaccination or a negative Covid -19 result 72 hours before schedule shift. Clinical manager will schedule a Inservice to orientate all staff member the importance of State and federal compliance related to Covid-19.
The administrator will do quarterly audits until the Agency has reached a 100% Threshold. The Human Resource Manager will be responsible for collecting proof of vaccination before hire date. The Human resource manager will be responsible to support employees who are required to test twice weekly.
All personnel files will have Proof of vaccination by 3/25/2022
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 policy, personnel files (PF), and an interview with administrator, the agency failed to provide documentation of signed job descriptions for three (3) of five (5) PF's reviewed, (PF #1, 2, and 5); and failed to provide documentation of an annual performance evaluations for four (4) of five (5) PF's reviewed, (PF #1, 2, 4, and 5).
Findings Included:
A review of agency policy titled "Employee Polices and Procedures" on March 9, 2022 at approximately 9:40 am states, "Job Description: Each agency employee will have a signed job description for each position within the agency at time of hire, annually, and whenever the job description changes..."
A review of agency policy titled " Performance Evaluations/Skills Competency Evaluations" on March 9, 2022 at approximately 9:50 am states, "General Statement: Performance evaluations are required for every employee and skills competency evaluations are required for all direct and contracted field staff. Skills competency evaluations are required for all field staff, on hire before a field staff member can visit a patient in their home. A performance evaluation is required 90 days after hire date. Both types of evaluations are next required 12 months after the employee's hire date, and then annually thereafter..."
A review of PF's conducted on March 8, 2022 from approximately 2:00 pm to 3:00 pm revealed the following:
PF #1, Date of Hire 2/28/15, did not contain any documentation of a signed job description for position of administrator and did not contain any documentation of an annual performance evaluation for 2019 or 2021.
PF#2, Date of Hire 10/28/2020, contained a job description for the position of director of nursing that was not signed and did not contain any documentation of an annual performance evaluation for 2021.
PF#4, Date of Hire 11/11/19, did not contain any documentation of an annual performance evaluation for 2021 and did not contain any documentation of an annual skills competency for 2021.
PF#5, Date of Hire: 2/19/18, did not contain any documentation of a signed job description for the position of alternate administrator and did not contain documentation of an annual performance evaluation for 2021.
An interview with the administrator on March 9, 2022, at approximately 11:30 am confirmed the above findings.
Plan of Correction:The Administrator will orientate the human resource department on the importance of collecting documentation of signed job descriptions during the onboarding period. The Administrator will audit all personnel files quarterly to ensure a threshold of 100% compliance
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 a review of agency policy, clinical record (CR) reviews, and an interview with the administrator, the agency failed to clarify, obtain, and reconcile the Medication Record with the current Home Health Certification and Plan of Care/physician orders allowing the potential for medication errors for four (4) of four (4) CR's reviewed, (CR #1, 2, 3, and 4); and the agency failed to follow its policy regarding items to be included in the plan of care for three (3) of three (4) CR reviewed. (CR #1, 2, and 3). The agency also failed to follow its policy regarding obtaining the physician's signature on the plan of treatment for four (4) of four (4) CR's reviewed, (CR #1, 2, 3, and 4); and failed to obtain a new recertification Home Health Certification and Plan of Care for the continuation of services for one (1) of one (1) CR reviewed, (CR #3).
Findings include:
A review of policy titled "Medication Profile" completed on March 9, 2022 at approximately 10:15 am states, "Policy: The medication list is collectively maintained in the clinical record. The plan of care will demonstrate the patient's current medication regimen, and additions and/or modifications will be identified in clinical notes, progress notes, summary reports, or communication notes. Agency staff will check all medicines a patient may be taking to identify possible ineffective drug therapy of adverse reactions, significant side effects, drug allergies, and contraindicated medication, and will promptly report any problems to the physcian...The medication profiles must be updated at least every sixty (60) days and whenever there is a change in the medication regime..."
A review of policy titled "Physician's Plan of Treatment" completed on March 9, 2022 at approximately 10:25 am states, "5. A physician's plan of treatment must be signed by the physician and in the chart within seven days of completion and must include:...b. The type of services and equipment needed. c. Frequency of visits needed...e. Medications and treatments...10. Any changes in the physician's plan of treatment shall be made in witting and signed and dated by the physician...The physician's plan of treatment shall be reviewed by the attending physician in consultation with the agency's professional personnel, at such interval as the severity of the patient's illness requires, but no to exceed sixty days for patients receiving skilled or unskilled services..."
A review of policy titled "Physician Responsibilities" completed on March 9, 2022 at approximately 10:30 am states, "Verbal/Telephone Orders. Policy: Signed physician's orders, which are signed and dated by the physician, are required for all services rendered by the Agency. All verbal or telephone orders will be received by licensed personnel...Procedure:...2. The Physician Order form is reviewed by the Director of Nursing or designee within 24 hours of receipt of verbal/telephone order..."
A review of CR's was conducted on March 8, 2022 from approximately 11:15 am to 2:00 pm revealed the following:
CR #1, Start of Care: 2/18/2022, Home Health Certification and Plan of Care period reviewed 2/18/2022 through 4/18/2022 did not contain any medication orders and no documentation of a completed medication profile. Discharge documentation from Jefferson Health dated 1/13/2022 contains documentation for the following medications:
1. Bisacodyl (Dulcolax) 10 mg suppository. Insert 10 mg into the rectum daily.
2. Diclofenac (Voltaren) 1% gel. Apply 2 grams topically four times a day.
3. Hydralazine (Apresoline) 10 mg tablet. Take 10 mg by mouth three times a day.
4. Lisinopril (Zestril) 40 mg tablet. Take 1 tablet by mouth daily.
5. Senna (Senokot) 8.6 mg tablet. Take 1 tablet by mouth daily.
6. Sertraline (Zoloft) 25 mg tablet. Take 1 tablet by mouth daily.
Home Health Certification and Plan of Care period reviewed 2/18/2022 through 4/18/2022 also contained an order for Home Health Aide (HHA) that states "HHA to provide assistance with personal care and activities of daily living (ADL's) as indicated by limitations on functional and physical status impeding self-care. Order does not contain frequency or duration of HHA visits to be provided.
Documentation in record indicates Home Health Certification and Plan of Care period for 2/18/2022 through 4/18/2022 was not sent to the physician for signature until 3/2/2022 and no physician signed copy of the Home Health Certification and Plan of Care for this period is in the record.
CR #2, Start of Care: 2/21/2022. Home Health Certification and Plan of Care period reviewed 2/21/2022 through 4/21/2022 did not contain any medication orders and no documentation of a completed medication profile. Primary Care Physician documentation dated 2/11/2022 contains documentation for the following medications:
1. Acetaminophen 500 mg = 1 tab oral every 4 hours for pain not to exceed 3000 mg/day.
2. Albuterol inhaler 90 mcg = 1 puff inhalation every 6 hours as needed shortness of breath.
3. Amlodipine 10 mg = 1 tab oral every day.
4. Aspirin 81 mg = 1 tab oral every day.
5. Atenolol 50 mg = 1 tag oral twice daily.
6. Clopidogrel 75 mg = 1 tab oral every day.
7. Fluticasone-Salmeterol (Advair Diskus) 250mcg/50mcg inhaler = 2 puffs inhalation twice daily.
8. Glipizide 10 mg = 1 tab oral every day.
9. Hydralazine 50 mg = 1 tab oral every 8 hours.
10. Hydrochlorothiazide 25 mg = 1 tab oral every day.
11. Lisinopril 40 mg = 1 tab oral every day.
12. Pregabalin 150 mg = 1 capsule oral twice a day.
13. Rosuvastatin 40 mg = 1 tab oral every night.
14. Lantus Solostar Pen 100 units/ml subcutaneous (SC) solution = 15 units SC every night.
15. Lyrica 150 mg = 1 capsule oral twice daily.
16. Nitrostat 0.3 mg = 1 tab sublingual every 5 minutes as needed.
17. Omega-3 1000 mg = 1 capsule oral every day.
18. Tramadol 50 mg = 1 tab oral every 4 hours as needed for pain.
Record contains a Physician's verbal order dated 3/2/2022 from PT that states "Patient's diagnosis includes hypertension and insulin dependent diabetes. She requires nursing visits to help her monitor her blood pressure and blood sugar levels and give instructions and monitor her medications, ingestible and oral." Order does not contain frequency or duration of nursing visits to be provided.
Documentation in record indicates Home Health Certification and Plan of Care period for 2/21/2022 through 4/21/2022 was not sent to the physician for signature until 3/2/2022 and no physician signed copy of the Home Health Certification and Plan of Care for this period is in the record.
CR #3, Start of Care: 9/27/2021. Discharge Date: 12/6/2021. Home Health Certification and Plan of Care period reviewed 9/27/2021 through 11/25/2021 contained the following medication orders:
1. Citalopram HBR 40 mg. 1 tab by mouth nightly.
2. Levocetirizine 5mg. 1 tab by mouth daily.
3. Omerazole DR 20 mg. 1 capsule by mouth every day 30 minutes before morning meal.
4. Cyclopentolate HCL. 2 drops into left eye twice daily.
5. Durezol 0.05%. 1 drop into the left eye four times daily.
Medication Profile dated 9/27/2021 contained the following medication:
1. Citalopram 10 mg. 1 tablet daily.
2. Cyclopentolate 10 mg. 1 tablet as needed.
The Medication Profile did not contain the medications as ordered on the Home Health Certification and Plan of Care for this certification period.
Home Health Certification and Plan of Care period reviewed 9/27/2021 through 11/25/2021 contains an order for physical therapy (PT) that states "PT evaluation completed; need for further visits" Order does not contain frequency or duration of PT visits to be provided.
There is no documentation in record of a physician signed Home Health Certification and Plan of Care for this period is in the record. There is no documentation of a Home Health Certification and Plan of Care for the period of 11/25/2021 through discharge date of 12/6/2021.
CR #4, Start of Care: 10/8/2021. Discharge Date: 12/6/2021. Home Health Certification and Plan of Care period reviewed 10/8/2021 through 12/6/2021 contained the following medication orders:
1. Cetirizine HCL 10 mg. 1 tab by mouth at bedtime as needed. Order does not contain a reason for medication.
2. Albuterol Sulfate HFA inhalation as needed. Order does not contain dosage, frequency, or reason for medication.
3. Myrbetriq ER 50 mg. 1 tab by mouth daily.
4. Fluticasone Propionate Salmeterol Diskus Inhalation 250/50 mcg. 250/50 mcg inhalation twice daily.
5. Senna 8.6 mg. 1 tab by mouth twice daily.
6. Pain relief 500 mg. 1 tab by mouth every 4 to 6 hours as needed. This order does not contain medication name and contains a range for frequency.
7. Naproxen 500 mg. 1 tab by mouth twice daily with food.
8. Cyclobenzaprine HCL 10 mg. 1 tab by mouth with food for pain every hours as needed.
There is no documentation of a completed medication profile in record.
There is no documentation in record of a physician signed Home Health Certification and Plan of Care for this period is in the record.
An interview with the administrator on March 9, 2022 at approximately 11:30 am confirmed the above findings.
Plan of Correction:The clinical manager will orientate all clinicians on the Medication profile and Plan of Care procedures by 3/25/2022.
The orientation will consist of Medication reconciliation, Plan of care and the time requirements for completing assessments & obtaining orders. The Administrator will audit quarterly until 100% compliance threshold is reached.
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 record (CR) reviews, and interview with the administrator, the agency failed to provide care/physician's orders in accordance with the plan of care for four (4) of four (4) CR's reviewed, (CR #1, 2, 3, and 4).
Findings include:
A review of agency policy titled "Submission of Clinical Record Visits" completed on March 9, 2022 at approximately 10:30 am states, "All initial assessments must be submitted within 48 hours. All nursing visit notes must be submitted within 7 days of providing services and must be filed in the patient's chart within 14 days of the visit. Home Health Aide notes must be submitted once weekly with their time sheets. Therapy services must be initiated within 5 days of receipt of the referral or as otherwise stated by state regulations requiring earlier initial visits. Therapy notes must be submitted within 7 days of the visit and discharges must be completed and filed within 30 days of discharge."
A review of agency policy titled "Patient Notification of Changes" completed on March 9, 2022 at approximately 10:35 am states, "Procedure:...4. When it is anticipated a visit cannot be made because of an unforeseen situation, the agency staff will immediately notify the office...b. If the patient refuses the alternate direct care staff and the visit cannot be rescheduled, the agency staff will complete a Missed Visit Report. The physician, PA, or ARNP will be notified that the plan of care frequency was not followed and the reason why. An order will be obtained to accommodate scheduled frequency as appropriate. c. All documentation regarding the missed visit will be placed in the patient record."
A review of CR's was conducted on March 8, 2022 from approximately 11:15 am to 2:00 pm revealed the following:
CR #1, Start of Care: 2/18/2022. Home Health Certification and Plan of Care Certification period reviewed 2/18/2022 through 4/18/2022, contained orders for physical therapy (PT) two (2) visits per week for eight (8) weeks and Home Health Aide (HHA) with no frequency or duration documented. Visit documentation revealed no documentation of PT visits completed past the initial assessment date of 2/18/2022. Visit documentation revealed no documentation of HHA visit completed. There is no documentation in file to indicate if visits were missed or if the physician was notified of the missed visits.
CR#2, Start of Care: 2/21/2022. Home Health Certification and Plan of Care Certification period reviewed 2/21/2022 through 4/21/2022 contained orders for PT of two (2) visits per week for eight (8) weeks. Visit documentation revealed no documentation of PT visit notes past the initial assessment date of 2/21/2022. A verbal order was obtained on 3/2/2022 for Skilled Nursing (SN) with no frequency or duration documented. Visit documentation revealed no documentation of SN visits completed. There is no documentation in file to indicate if visits were missed or if the physician was notified of the missed visits.
CR#3, Start of Care: 9/27/2021. Home Health Certification and Plan of Care Certification period reviewed 9/27/2021 through 11/25/2021 contained orders for PT with no frequency or duration documented. PT evaluation documents visits as two (2) times per week for four (4) weeks. Visit documentation revealed no PT visit documentation for the week of 10/25/2021 through 10/31/2021 and there is no documentation of missed visits. There is only documentation of one (1) PT visit for the week of 11/1/2021 through 11/7/2021 and there is no documentation of a missed visit. There is only documentation of one (1) PT visit for the week of 11/8/2021 through 11/14/2021 and there is no documentation of a missed visit. There is no documentation of PT visits from 11/15/2021 through discharge date of 12/6/2021 and there is no documentation of a missed visits. There is no documentation in file to indicate if the physician was notified of the missed visits.
CR #4, Start of Care: 10/8/2021. Home Health Certification and Plan of Care Certification period reviewed 10/8/2021 through 12/6/2021 contained orders for PT for one (1) visit for one (1) week, then two (2) visits per week for five (5) weeks. Visit documentation revealed PT initial assessment was completed on 10/20/2021. There is no documentation of PT missed visits for the time period of 10/8/2021 through 10/20/2021. There is no documentation of PT visits from 10/21/2021 through 11/14/2021 and no documentation of missed visits. For the week of 11/22/2021 through 11/28/2021, there is documentation of only one (1) PT visit and no documentation of a missed visit. For the week of 11/28/2021 through 12/5/2021, there is documentation of only one (1) PT visit and no documentation of a missed visit. There is no documentation in file to indicate the physician was notified of the missed visits.
An interview with the administrator conducted March 9, 2022 at approximately 11:30 am confirmed the above findings.
Plan of Correction:The clinical manager will be responsible to orientate all clinician by 3/25/2022 that all nursing visit notes must be submitted within 7 days of providing services and must be filed in the patient's chart within 14 days of the visit. Home Health Aide notes must be submitted once weekly with their time sheets. Therapy services must be initiated within 5 days of receipt of the referral or as otherwise stated by state regulations requiring earlier initial visits. Therapy notes must be submitted within 7 days of the visit and discharges must be completed and filed within 30 days of discharge.
The Clinical manager will be responsible to audit documentation weekly to ensure a 100% compliance threshold.
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 a review of agency policies, clinical records (CR), and interview with the administrator, it was determined that the agency failed to follow its policies regarding: documentation and submission of sixty (60) day summaries for four (4) of four (4) CR's reviewed with sixty (60) day summaries (CR #1, 8, 9, and 10), documentation and submission of transfer of agency services for four (4) of four (4) CR's with services that were transferred (CR #3, 6, 8, and 9), and documentation and submission of discharge summaries for two (2) of two (2) discharged CR's (CR #11 and 12).
Findings include:
A review of agency policy titled "Clinical Record Contents" on March 9, 2022 at approximately 10:45 am states, "The agency maintains a confidential clinical record for each patient admitted to care. Closed or previously discharged records do not become current files if the patient is readmitted to services. The clinical record includes the following information: 11. Discharge Summary: a. A discharge summary is to be completed on all patients discharged from the agency It is to be completed within thrity (30) days o discharge and is to include: i. Patient status upon discharge. ii. Recommendations and referral for any follow-up care, if needed..."
A review of agency policy titled "Discharge/Transfer Policy" on March 9, 2022 at approximately 11:00 am states, "5. All discharged patients will have required documentation to ensure appropriate communication is provided to the physician, as requested...Completion of Discharged Records: In order to verify closure of inactive records, all clinical records will be completed and audited within thirty days of discharge as follows: 1. The clinical record of a discharged patient is fully completed, including a discharge summary in ten working days..."
A review of agency policy titled "Submission of Clinical Record Visits" completed on March 9, 2022 at approximately 10:30 am states, "All initial assessments must be submitted within 48 hours. All nursing visit notes must be submitted within 7 days of providing services and must be filed in the patient's chart within 14 days of the visit. Home Health Aide notes must be submitted once weekly with their time sheets. Therapy services must be initiated within 5 days of receipt of the referral or as otherwise stated by state regulations requiring earlier initial visits. Therapy notes must be submitted within 7 days of the visit and discharges must be completed and filed within 30 days of discharge."
A review of CR's was conducted on March 8, 2022 from approximately 11:15 am to 2:00 pm revealed the following:
CR #3, Start of Care: 9/27/2021. Discharge Date: 12/3/2021. Home Health Certification and Plan of Care period reviewed: 9/27/2021 through 11/25/2021. Visit documentation indicates Physical Therapy (PT) discharge assessment was completed on 12/3/2021. There is no documentation of a discharge summary, no documentation that the physician was notified of discharge, or that a discharge summary was sent to the physician.
CR #4, Start of Care: 10/8/2021. Discharge Date: 12/6/2021. Home Health Certification and Plan of Care period reviewed: 10/8/2021 through 12/6/2021. Visit documentation indicates Physical Therapy (PT) discharge assessment was completed on 12/6/2021. There is no documentation of a discharge summary, no documentation that the physician was notified of discharge, or that a discharge summary was sent to the physician.
An interview with the administrator on March 9, 2022 at approximately 11:30 am confirmed the above findings.
Plan of Correction:The clinical manager is responsible for orientating all clinicians to make sure discharge summary is to be completed on all patients discharged from the agency It is to be completed within thrity (30) days of discharge and is to include: Patient status upon discharge. Recommendations and referral for any follow-up care that is needed.
He administrator will audit clinical records Quarterly to ensure a 100% compliance threshold.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 8, 2022 and March 9, 2022, Weallcare 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 onsite unannounced state re-licensure survey conducted on March 8, 2022 and March 9, 2022, Weallcare 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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