Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted July 21, 2022, Daily Dove Care, 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, personnel file reviews (PF), and interview with the Agency's Administrator, it was determined the agency failed to follow agency policy to ensure that personnel files contain initial competency checklist, and orientation for two (2) of four (4) PF reviewed (PF # 3 & 4) and failed to follow policy to ensure that personnel files contained job description, Pennsylvania Background check, yearly Compentency, TB screening and CPR certification for one (1) of four (4) PF reviewed (PF #3).
Findings include:
A review of agency policy titled was conducted on 7/21/22 at approximately 12:30 P.M. which revealed:
Policy titled, "Personnel Records" states, "The personnel record or personnel information for an employee will include, but not limited to the following: Observed competencies initial during orientation and ongoing...CPR if required...agency employee orientation...Criminal history check if required by law, job description reviewed and signed by employee..The health record for applicable employees with include: PPD tests or Chest X-Ray results based on agency's TB risk assessment...Personnel records will also include: annual evaluation of job duties, annual performance evaluation, initial PPD or X-ray screening and annual verification of PPD or TB symptom tool..."
A review of personnel files was conducted on 7/12/22 at approximately 11:30 AM which revealed the following:
PF #3, Date of Hire: 11/1/19. The PF did not contain documentation of initial competency checklist, orientation, signed job description, PA State Criminal Background Check, Yearly Compentency evaluations since hire, TB screening and CPR certification completed.
PF #4, Date of Hire: 5/3/21. The PF did not contain documentation of initial competency checklist or orientation completed.
Interview with the Agency's Administrator on 7/21/22 at approximately 1:30 P.M. confirmed the above findings.
Plan of Correction:According to our Policy "Personnel Records"
PF#3 will have the initial competency checklist, orientation, signed job description, PA State Criminal Background Check, Yearly Competency evaluations since hire completed, TB screening and CPR certification completed.
PF#4-Will have documentation of initial competency checklist and orientation completed.
All New W2 and contracted employees will have personnel record information include, but not limited to the following: Observed competencies initial during orientation and ongoing...CPR if required...agency employee orientation...Criminal history check if required by law, job description reviewed and signed by employee. The health record for applicable employees with include: PPD tests or Chest X-Ray results based on agency's TB risk assessment...Personnel records will also include: annual evaluation of job duties, annual performance evaluation, initial PPD or X-ray screening and annual verification of PPD or TB symptom tool..."
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 upon clinical record review, and an interview with the Administrator, it was determined the agency failed to provide services according to the plan of care for one (1) of five (5) clinical records reviewed. (CR # 5) and the agency failed to ensure visit duration was listed on the Plan of Care for five (5) of five (5) clinical records reviewed (CR#1, 2, 3, 4 & 5).
Findings include:
Policies were reviewed on 7/21/22 at approximately 12:00 PM and revealed the following:
Policy titled, "Plan of Care- CMS #485 and Physician Orders" states, "Skilled Nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources...Each patient must receive an individualized written plan of care, including any revisions or additions...The individualized plan of care must include the following...the frequency and duration of visits to be made...All patient care orders, including verbal orders, must be recorded in the plan of care...Any revisions related to the plan of care due to a change in patient health status must be communicated to the patient, representative, caregiver and all physicians issuing order for the agency plan of care...consultation with the physician on any modification in the plan of care will de documented and the physician's signature obtained according the the state law...the agency professional staff will promptly alert the physician to any changes..care and services provided will be provided according to the physician orders...If the agency provides fewer visits than the physican orders, it has altered the plan of care and the physician must be notified. The agency must maintain documentation in the clinical record indicating that the physician was notified and is aware of the missed visit..."
Clinical records were reviewed on 7/21/22 at approximately 10:00 AM and revealed the following:
CR#1 (Start of Care: 10/29/21) Certification period reviewed: 6/26/22 through 8/24/22. Skilled Nursing ordered for once weekly. There was no listed duration on the plan of care.
CR#2 (Start of Care: 2/26/22) Certification period reviewed: 6/26/22 through 8/24/22. Skilled Nursing ordered for twice weekly. There was no listed duration on the plan of care.
CR#3 (Start of Care: 11/21/21) Certification period reviewed: 7/7/22 through 9/4/22. Skilled Nursing ordered for once weekly. There was no listed duration on the plan of care.
CR#4 (Start of Care: 2/4/22) Certification period reviewed: 6/4/22 through 8/2/22. Skilled Nursing ordered for twice weekly. There was no listed duration on the plan of care.
CR #5 (Start of Care: 11/18/21). Certification period reviewed: 11/18/21 through 1/16/22. Skilled Nursing ordered for twice weekly. There was no listed duration on the plan of care. In addition, the last skilled nursing visit was conducted by agency on 12/7/21. There were no skilled nursing visits conducted from 12/8/21-1/16/22. There was no documented evidence of physician notification and/or physician order to revise the plan of care. Patient was discharged from the agency on 1/16/22.
An interview the Administrator on 7/21/22 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:CR#1 (Start of Care: 10/29/21) Certification period reviewed: 6/26/22 through 8/24/22. Skilled Nursing ordered for once weekly. There was no listed duration on the plan of care.
Visits will be listed in the plan of care for the duration of certification period.
CR#2 (Start of Care: 2/26/22) Certification period reviewed: 6/26/22 through 8/24/22. Skilled Nursing ordered for twice weekly. There was no listed duration on the plan of care.
Visits will be listed in the plan of care for the duration of certification period.
CR#3 (Start of Care: 11/21/21) Certification period reviewed: 7/7/22 through 9/4/22. Skilled Nursing ordered for once weekly. There was no listed duration on the plan of care.
CR#4 (Start of Care: 2/4/22) Certification period reviewed: 6/4/22 through 8/2/22. Skilled Nursing ordered for twice weekly. There was no listed duration on the plan of care.
Visits will be listed in the plan of care for the duration of certification period.
CR #5 (Start of Care: 11/18/21). Certification period reviewed: 11/18/21 through 1/16/22. Skilled Nursing ordered for twice weekly. There was no listed duration on the plan of care. In addition, the last skilled nursing visit was conducted by agency on 12/7/21. There were no skilled nursing visits conducted from 12/8/21-1/16/22. There was no documented evidence of physician notification and/or physician order to revise the plan of care. Patient was discharged from the agency on 1/16/22.
Physician will be notified immediately of missed visits and reason. If the patient continues to cancel and miss visits the physician will be notified and the patient will be discharged by the agency and a discharge OASIS will be sent to the physician.
Following our policy:
Policy titled, "Plan of Care- CMS #485 and Physician Orders" states, "Skilled Nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources...Each patient must receive an individualized written plan of care, including any revisions or additions...The individualized plan of care must include the following...the frequency and duration of visits to be made...All patient care orders, including verbal orders, must be recorded in the plan of care...Any revisions related to the plan of care due to a change in patient health status must be communicated to the patient, representative, caregiver and all physicians issuing order for the agency plan of care...consultation with the physician on any modification in the plan of care will documented and the physician's signature obtained according the state law...the agency professional staff will promptly alert the physician to any changes of care and services provided will be provided according to the physician orders...If the agency provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified. The agency must maintain documentation in the clinical record indicating that the physician was notified and is aware of the missed visit..."
All patients will receive an individualized written plan of care, including duration of visits. Physician will be made aware of plan of care and any changes to plan of care and any changes with patient and visits. Physician signature will be obtained for any changes to the plan of care. The patient will also be made aware of any changes to the plan of care and any visits and be agreeable to plan of care.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on July 21, 2022, Daily Dove Care, 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 state re-licensure survey conducted on July 21, 2022, Daily Dove Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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