Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey concluded on February 16, 2023, Comforcare Home Care- Chester County South, was found to not 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 upon review of the Pennsylvania Child Protective Services Act, Review of the Pennsylvania adult protective Services Act, personnel file (PF) review, interview with Registerd Nurse #1, and interview with the agency administrator, it was determined the agency failed to ensure personnel who have regular contact with patients under the age of eighteen, to have required clearances, for three (3) out of three (3) personnel files reviewed (PF#1-PF#3), and failed to ensure personnel have the required clearances per the Adult Protective Services Act for two (2) out of three (3) personnel files reviewed (PF#2 and PF#3).
Findings include:
Review of https://www.dhs.pa.gov/KeepKidsSafe/Clearances/Pages/default.aspx on 2/15/2023 at approximately 3:00 PM states:
"Clearances are required for an employee or unpaid volunteer at a minimum of every 60 months from the date of the oldest clearance. Clearances may be required more frequently based on licensure or employer requirements.
Agencies and organizations must ensure that clearances are obtained in accordance with the CPSL. The required clearances may include:
Pennsylvania Child Abuse History Clearance
Pennsylvania State Police Criminal History Clearance
Federal Bureau of Investigations (FBI) Criminal History Clearance
(required for all employees and some volunteers)"
Review of the Pennsylvania Adult Protective Services Act on 2/15/2023 at approximately 3:15 PM states, According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."
Personnel files reviewed on 2/15/23 at from approximately 11:00 AM-11:15 AM revealed the following:
PF#1 (Date of hire: 1/05/2023): No documentation of a FBI Criminal History Clearance nor Pennsylvania Child Abuse History Clearance.
PF#2 (Date of hire: not documented, estimated to be approximately 2017 per Registered Nurse #1): No documentation of a FBI Criminal History Clearance nor Pennsylvania Child Abuse History Clearance. Professional Nursing License for PF#2 revealed an out of state (Delaware) address.
PF#3 (Date of hire: not documented, estimated to be approximately 2017 per Registered Nurse #1): No documentation of a Pennsylvania Child Abuse History Clearance, Pennsylvania State Police Criminal History Clearance, nor FBI Criminal History Clearance.
An interview conducted with RN#1 on 2/15/2023 at approximately 11:15 AM confirmed the agency had provided Nursing Services to a patient under the age of eighteen years old in 2022 (Clinical Record #5).
An interview conducted with the agency administrator conducted on 2/15/2023 at approximately 1:00 PM confirmed the agency plans on accepting future referrals for patients under the age of eighteen years old. Confirmed the above findings.
Plan of Correction:1. Agency will update policy per Pennsylvania child protective services act and Pennsylvania adult protectives act to require all employees working with a patient under the age of 18 to complete clearances in accordance with the CPSL. The required clearances may include:
Pennsylvania Child Abuse History Clearance
Pennsylvania State Police Criminal History Clearance
Federal Bureau of Investigations (FBI) Criminal History Clearance
(required for all employees and some volunteers)"
Clearances are required for an employee or unpaid volunteer at a minimum of every 60 months from the date of the oldest clearance.
Clearances will be completed according to the policy for all active employees who are willing to work with clients under the age of 18. All new hire candidates interested in working with pediatrics will be required to complete all clearances upon hire.
RN#2 needs a FBI (out of state) and RN#1 PATCH documentation of. All three employees will have all three background checks before corrective action date.
The agency will also add a pediatrics checklist to hiring documents with instructions and completion dates to obtain clearances.
To monitor the correction action, the administrator will perform new hire audits of personnel and pediatric clients files during hiring and quality reviews to ensure compliance with policy/standards.
601.21(e) REQUIREMENT
SUPERVISING PHYS OR REGISTERED NURSE
Name - Component - 00
601.21(e) Supervising Physician or
Registered Nurse. The skilled nursing
and other therapeutic services
provided are under the supervision and
direction of a physician or a
registered nurse (with at least one
year of nursing experience). This
person or similarly qualified
alternate, is available at all times
during operating hours and
participates in all activities
relevant to the professional services
provided, including the development of
qualifications and assignment of
personnel.
Observations:
Based on review of the agency's organizational chart, interview with Registered Nurse #1, and license verification via the Pennsylvania Department of State Licensing System Verification Service", it was determined the agency failed to ensure the practice of professional nursing was conducted by a professional with a current active registered nurse license for the agency's supervising Registered Nurse (RN#1), and failed to ensure the agency's Supervising Registered Nurse to hold a current up to date license, for January 2023 and February 2023.
Findings include:
There was no personnel file for review for RN#1 at the agency on 2/15/2023.
Review of the agency's organization chart on 2/15/2023 at approximately 10:00 AM lists RN#1 as the agency's supervising Registered Nurse.
Review of the "Pennsylvania Licensing System Verification" service on 2/16/2023 at approximately 9:30 AM lists RN#1 status as "expired" as a Registered Nurse effective 12/31/2022.
Interview with RN#1 on 2/15/2023 at approximatley 10:05 AM confirmed RN #1 as currently holding the position as the agency's supervising registered nurse and confirmed RN#1 provided nursing services to agency patients in January 2023 and February 2023.
Plan of Correction:1. Agency is in the process of hiring a new supervising RN. The backup nurse will work as needed to complete nursing tasks. The back up nurse is a active licensed RN and an employee of agency
Actively monitor and track expiration dates for all active licensed personnel. All personnel files will be reviewed and license expiration dates tracked in Swyftops. Alerts will be set for the office and staff to be notified by the system of upcoming license renewal. Any staff with lapsed license must immediately reinstate license to continue working.
2. Employee record review will be completed and all expiration dates updated and uploaded in Swyftops for automatic tracking and notification
3. All staff will be trained on the requirement to keep licenses current. Also, automatic tracking will be implemented using software (Swyftops).
4. Corrective action will be monitored during quarterly reviews of employment records during quarterly quality reviews including licensing reviews for all staff.
5. Complete by 4/16/2023 all staff will have current license and tracking in place to office and employee 60 days prior to expiration.
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 policy review, personnel file (PF) review, interview with Registered Nurse #1 (RN#1) and an interview with the agency administrator, it was determined the agency failed to ensure documention of qualifications in the employee personnel file for two out of three PF's reviewed (PF#2 and PF#3), failed to ensure documentation of current professional licensure in the employee personnel file for two out of three PF's reviewed (PF#2 and PF#3), failed to ensure documenation of a competency evaluation in the employee personnel file for three out of three PF's reviewed (PF#1 -PF#3), failed to ensure documentation of complete tuberculosis health screenings in the employee personnel file for three out of three PF's reviewed (PF#1 - PF#3), and failed to ensure documenation of job descriptions in the personnel file for two (2) out of three (3) personnel files reviewed (PF#2 and PF#3).
Findings include:
Review of policy "Health Screening" on 2/15/2023 at approximately 12:05 PM states "...1. All direct care personnel will complete a TB Risk Assessment upon hire...2. All direct care personnel will be screened for symptoms of TB upon hire....using a TB screening questionnaire....3. All direct care personnel will have a documented TB test in their personnel file prior to providing care....5. ....if the Mantoux skin testing method is used for baseline TB testing, the 2-step method should be used....."
Review of policy "Competency Evaluations" on 2/15/2023 at approximately 12:10 PM states ...1. All new employees will be assessed for competency based on the expected requirements for the position...resumes and reference checks will verify the education and professional experience of each individual prior to accepting the position with the agency....3. Competency assessments will be completed on all direct care personnel at the following intervals a. initially during orientation and prior to independently providing care/services...4. documentation of competency evaluations will be maintained in the personnel file....6. annual performance reviews will address competencies in the areas of essential function..."
Personnel files reviewed on 2/15/23 at from approximately 11:00 AM-11:15 AM revealed the following:
PF#1/ Home Health Aide #1 (Date of hire: 1/05/2023): No documentation of a TB risk assessment nor baseline TB testing nor documention of an initial competency evaluation
PF#2 (Date of hire: not documented, estimated to be approximately 2017 per Registered Nurse #1): No documentation of a TB risk assessment, TB symptom screening nor baseline TB testing, no documenation of a job description, no documention of a current Registered Nurse License (Registered Nurse license with an expiration date 4/30/18 provided to the surveyor), no documention of an initial competency evaluation nor an annual competency/performance evaluation for 2018-2023, no documention of qualifications.
PF#3 (Date of hire: not documented, estimated to be approximately 2017 per Registered Nurse #1): No documentation of a TB risk assessment, TB symptom screening nor baseline TB testing, no documenation of a job description, No documentation of a current Registered Nurse license, no documention of an initial competency evaluation nor an annual competency/performance evaluation for 2018-2023, no documentation of qualifications.
An interview with the agency administrator on 2/15/2023 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:1. All personnel and files will be reviewed, evaluated and updated with proper written documentation including but not limited to: date of hire, job description, competency evaluations, 2-Step TB baseline, performance evaluations, current licensure in employee files and references. Licensed nurses will have qualifications in their personnel records.
2. This corrective action applies to all employees.
3. The hiring process will be standardized and the checklist updated to include these requirements for all new hires. Performance Evaluations will be added to annual agency review as a action/tasks to be completed.
4. Employee files will be audited and monitored to requirement during quarterly quality reviews. Employee file reviews will also be added to the agenda for the annual review evaluation. Administrator is responsible.
5. Actions will be completed by 4/16/2023
601.22(c) REQUIREMENT
ANNUAL PROGRAM EVALUATION
Name - Component - 00
601.22(c) Annual Program Evaluation.
The home health agency has written
policies requiring an overall
evaluation of the agency's total
program at least once a year by: (i)
the group of professional personnel
(or a committee of this group), agency
staff and consumers, or by (ii)
professional people outside the agency
working in conjunction with consumers.
The evaluation consists of an overall
policy and administrative review and a
clinical record review. The
evaluation assesses the extent to
which the agency's program is
appropriate, adequate, effective and
efficient. Results of the evaluation
are reported to and acted upon by
those responsible for the operation of
the agency and are maintained
separately as administrative records.
As a part of the evaluation process
the policies and administrative
practices of the agency are reviewed
to determine the extent to which they
promote patient care that is
appropriate, adequate, effective, and
efficient. Mechanisms are established
in writing for the collection of
pertinent data to assist in
evaluation. The data to be considered
may include but are not limited to:
number of patients receiving each
service offered, number of patient
visits, reasons for discharge,
breakdown by diagnosis, sources of
referral, number of patients not
accepted, with reasons, and total
staff days for each service offered.
Observations:
Based upon review of agency administrative documents and an interview with the agency administrator, it was determined the agency failed to ensure documention of an annual program evaluation for 2022.
Findings include:
Review of agency administrative documention on 2/15/2023 at approximately 12:30 PM revealed no documentation of an annual program evaluation for 2022.
An interview with the agency administrator on 2/15/2023 at approximately 12:35 PM confirmed the above findings.
Plan of Correction:1. 2022 Annual Evaluation Meeting is scheduled during 2023-Q1 quarterly review. Policy will be updated to include Annual Evaluation Meeting during at least 1 or more regular quarterly meetings to ensure it is documented properly.
2. The Professional Advisory Committee is affected by this corrective action.
3. 2022 Annual Evaluation will be completed and reviewed during 1 or more quarterly quality review meetings. The Evaluation will be documented in the quality binders.
4. The administrator is responsible for ensuring scheduling review meetings, completion of tasks and monitoring. Meetings will be documented in the Quality Review Binder.
5. Corrective action will be complete by 4/16/2023
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 records (CR), and interview with Registered Nurse (RN) #1, the agency failed to develop a plan of care in accordance with agency policy and regulatory standards for five (5) of five (5) clinical records (CR) reviewed (CR # 1, 2, 3, 4, and 5).
Findings include:
A review of policy #C280 titled " Plan of Care " on 2/15/2023 at approximately 12:15 P.M. stated, " Procedure: 1. An individualized Plan of Care (485) signed by a Physician shall be required for each client receiving Skilled Nursing Services or Skilled Nursing and Home Health Services. 2. The Plan of Care (485) shall be completed in full to include: d. Orders for specific clinical services, treatments, procedures (specify amount/frequency/duration) ... k. Measurable treatment goals ... m. Rehabilitation potential. n. Functional limitations and precautions. o. Activities permitted or restrictions ... u. Instructions for timely discharge or referral ... v. Discharge plans ... "
A review of clinical records on 2/15/ 2023, from approximately 11:00 A.M. to 12:00 P.M. revealed the following:
CR #1, Contains a Home Health Certification and Plan of Care (POC) with start of care date 11/14/2022, and certification period 1/8/2023 to 3/8/2023. The " Orders for Discipline and Treatments " contains no documentation of the scope, duration, or frequency of the visits to be performed. There are no specific orders for care to be provided at the visits. The POC does not contain measurable treatment goals, rehabilitation potential and discharge plans.
CR #2, Contains a Home Health Certification and Plan of Care (POC) with start of care date 11/10/2022, and certification period 1/8/2023 to 3/8/2023. The " Orders for Discipline and Treatments " contains no documentation of the scope, duration, or frequency of the visits to be performed. There are no specific orders for care to be provided at the visits. The POC does not contain measurable treatment goals, rehabilitation potential and discharge plans.
CR #3, Contains a Home Health Certification and Plan of Care (POC) with start of care date 9/12/2022, and certification period 1/8/2023 to 3/8/2023. The " Orders for Discipline and Treatments " contains no documentation of the scope, duration, or frequency of the visits to be performed. There are no specific orders for care to be provided at the visits. The POC does not contain measurable treatment goals, rehabilitation potential and discharge plans.
CR #4, Contains a Home Health Certification and Plan of Care (POC) with start of care date 6/15/2022, and certification period 11/28/2022 to 1/26/2023. The " Orders for Discipline and Treatments " contains no documentation of the scope, duration, or frequency of the visits to be performed. There are no specific orders for care to be provided at the visits. The POC does not contain measurable treatment goals, rehabilitation potential and discharge plans.
CR #5, Contains a Home Health Certification and Plan of Care (POC) with start of care date 6/13/2022, and certification period 2/1/2023 to 4/1/2023. The " Orders for Discipline and Treatments " contains no documentation of the scope, duration, or frequency of the visits to be performed. There are no specific orders for skilled care to be provided. Orders include non-skilled care tasks such as toileting, bathing, assist with breathing exercises, monitor for safety, and notify parents of seizures. The " Goals/Rehabilitation Potential/Discharge Plans " includes " Remain stable at home - Target: 8/4/2022. Client ' s need will be met by HHA care - Target: 8/4/2022. " There was no documentation of revision of the POC when goals were not met by 8/4/2022.
An interview conducted with RN #1 on 2/15/2023 at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:1. All plan of care (POC) will be revised per the procedure to include:
Procedure: 1. An individualized Plan of Care (485) signed by a Physician shall be required for each client receiving Skilled Nursing Services or Skilled Nursing and Home Health Services. 2. The Plan of Care (485) shall be completed in full to include: d. Orders for specific clinical services, treatments, procedures (specify amount/frequency/duration) ... k. Measurable treatment goals ... m. Rehabilitation potential. n. Functional limitations and precautions. o. Activities permitted or restrictions ... u. Instructions for timely discharge or referral ... v. Discharge plans ... and visit frequency will be added onto the Plan of Care.
All client POC will be revised per the procedure. This procedure will be the standard for creating POC for all clients.
2. All clients are affected by this policy. All active clients with POC will corrected.
3. Nurses will be training on how to properly complete a POC. A template will be created to ensure all necessary inputs are included on the POC form.
4.POC will be updated, reviewed and audited to ensure the deficieny is corrected. The Nurse supervisor is responsible for updating and revising POCs. The administrator is responsible for monitoring and auditing POC to procedure both prior to being sent to the doctor and during the quarterly quality reviews.
5. Corrective action complete 4/16/2023
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 (CR) and interview with Registered Nurse (RN) #1, it was determined the agency failed to ensure documentation of a sixty (60) day summary in the clinical record for five (5) out of five (5) CR's reviewed (CR #1, 2, 3, 4, and 5).
Findings include:
A review of policy #C280 titled " Plan of Care " on 2/15/2023 at approximately 12:15 P.M. stated, " Policy: ... The Plan of Care (commonly known as a 485) is based on a comprehensive assessment and information provided by the client/family and health team members ... The plan will be consistently reviewed to ensure client needs are met, and will be updated as necessary, but at least every (60) days ... Procedure: 1. An individualized Plan of Care (485) signed by a Physician shall be required for each client receiving Skilled Nursing Services or Skilled Nursing and Home Health Services. 2. The Plan of Care (485) shall be completed in full ... 5. The Plan of Care (485) will be developed following the Comprehensive Assessment by a Registered Nurse ... The Plan of Care (485) is developed within five (5) working days or as required by Agency/state guidelines. The written Plan of Care (485) must be signed by the Physician within 30 days and returned to the Agency ... 8. The total Plan of Care (485) shall be reviewed by the attending Physician and Agency personnel as often as the severity of the client ' s condition requires, but at least one time every sixty (60) days. 9. At the time of certification and recertification, a written summary of the client ' s current status and the services being provided are submitted with the Plan of Care (485) for review. The summary shall include, but is not limited to: changes in the client ' s physical or psychosocial condition, client response to care/services and outcome of care and services. 10. Professional staff shall promptly alert the Physician to any changes that suggest a need to alter the Plan of Care (485). 11. Verbal/telephone orders shall be obtained from the client ' s Physician for changes in the Plan of Care (485) ... "
A review of clinical records on 2/15/ 2023, from approximately 11:00 A.M. to 12:00 P.M. revealed the following:
CR #1, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 11/14/2022, and certification period 1/8/2023 to 3/8/2023. The CR contained an initial assessment completed on 11/8/2022. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services being provided at least every sixty (60) days.
CR #2, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 11/10/2022, and certification period 1/8/2023 to 3/8/2023. There was no documentation that the physician was provided a written summary of the patient ' s current status and services being provided at least every sixty (60) days.
CR #3, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 9/12/2022, and certification period 1/8/2023 to 3/8/2023. There was no documentation that the physician was provided a written summary of the patient ' s current status and services being provided at least every sixty (60) days.
CR #4, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 6/15/2022, and certification period 11/28/2022 to 1/26/2023. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services being provided at least every sixty (60) days.
CR #5, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 6/13/2022, and certification period 2/1/2023 to 4/1/2023. There was no documentation that the physician was provided a written summary of the patient ' s current status or services being provided at least every sixty (60) days.
An interview conducted with RN #1 on 2/15/2023 at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:1. Clinical Records will be updated per policy C280 to include a 60 day summary for all clients. The 60 day summary will be sent to the physican on an ongoing basis. The summary shall include, but is not limited to: changes in the client ' s physical or psychosocial condition, client response to care/services and outcome of care and services. Referral notes will to be included along with summary of services and current status for each patient.
2. All clients are affected by this deficiency.
3. Nurses will be trained on clinical record requirements and policy C280.
4. All clinical records will be reviewed and audited during regular quality reviews and every 60 day certification period. Reviews will be documented in the quality binder by the Administrator.
5. complete by 4/16/2023
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of agency policy, clinical records (CR) and interview with Registered Nurse (RN) #1, the RN failed to initiate the plan of treatment and necessary revisions, document review of the patient ' s medications (side effects, adverse reactions, and possible interactions with other medications) at least every 60 days, document regular assessments/reassessments to evaluate the patient's nursing needs, prepare clinical progress notes, and/or ensure physician ' s orders were signed in accordance with agency policy for five (5) of five (5) CR reviewed. (CR #1, 2, 3, 4, and 5).
Findings include:
A review of policy #C280 titled " Plan of Care " on 2/15/2023 at approximately 12:15 P.M. stated, " Policy: ... The Plan of Care (commonly known as a 485) is based on a comprehensive assessment and information provided by the client/family and health team members ... The plan will be consistently reviewed to ensure client needs are met, and will be updated as necessary, but at least every (60) days ... Procedure: 1. An individualized Plan of Care (485) signed by a Physician shall be required for each client receiving Skilled Nursing Services or Skilled Nursing and Home Health Services. 2. The Plan of Care (485) shall be completed in full ... 5. The Plan of Care (485) will be developed following the Comprehensive Assessment by a Registered Nurse ... The Plan of Care (485) is developed within five (5) working days or as required by Agency/state guidelines. The written Plan of Care (485) must be signed by the Physician within 30 days and returned to the Agency ... 8. The total Plan of Care (485) shall be reviewed by the attending Physician and Agency personnel as often as the severity of the client ' s condition requires, but at least one time every sixty (60) days. 9. At the time of certification and recertification, a written summary of the client ' s current status and the services being provided are submitted with the Plan of Care (485) for review. The summary shall include, but is not limited to: changes in the client ' s physical or psychosocial condition, client response to care/services and outcome of care and services. 10. Professional staff shall promptly alert the Physician to any changes that suggest a need to alter the Plan of Care (485). 11. Verbal/telephone orders shall be obtained from the client ' s Physician for changes in the Plan of Care (485) ... "
A review of clinical records on 2/15/ 2023, from approximately 11:00 A.M. to 12:00 P.M. revealed the following:
CR #1, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 11/14/2022, and certification period 1/8/2023 to 3/8/2023. The CR contained an initial assessment completed on 11/8/2022. There was no documentation of a reassessment of the patient prior to the current certification period. There was no documentation of a review of the patient ' s medications. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services being provided at least every sixty (60) days. There was one (1) skilled nursing visit documented during the certification period on 1/27/2023.
CR #2, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 11/10/2022, and certification period 1/8/2023 to 3/8/2023. The CR contained an initial assessment completed on 11/11/2022. There was no documentation of a reassessment of the patient prior to the current certification period. There was no documentation of a review of the patient ' s medications. There was no documentation that the physician was provided a written summary of the patient ' s current status and services being provided at least every sixty (60) days. There were no skilled nursing visits documented for the certification period. The initial POC dated 11/10/2022 was signed by the physician 1/13/2023, 64 days after the start of care.
CR #3, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 9/12/2022, and certification period 1/8/2023 to 3/8/2023. The CR contained an initial assessment completed on 9/9/2022. A reassessment was completed on 11/7/2022. There was no documentation of a reassessment of the patient prior to the current certification period. There was no documentation of a review of the patient ' s medications. There was no documentation that the physician was provided a written summary of the patient ' s current status and services being provided at least every sixty (60) days. There were no skilled nursing visits documented for the certification period. RN #1 documented visits on 1/19/2023, 1/27/2023, and 2/10/2023 in communication notes. There was no documentation of a skilled nursing assessment on the dates noted.
CR #4, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 6/15/2022, and certification period 11/28/2022 to 1/26/2023. There was no documentation that the POC for the certification period reviewed was signed by the attending physician. An initial assessment was completed on 11/16/2022. A reassessment was documented on 1/14/2023. There was no documentation of a review of the patient ' s medications. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services being provided at least every sixty (60) days. Skilled nursing visits were documented on 12/22/2022, and 1/14/2023. The patient was hospitalized during the certification period, but the dates were not documented. There was no documentation of an assessment completed post hospital discharge or if any new orders were obtained. The patient was discharged to a skilled nursing facility on 1/23/2023. There was no discharge summary or physician notification documented.
CR #5, No referral date noted, contains a Home Health Certification and Plan of Care (POC) with start of care date 6/13/2022, and certification period 2/1/2023 to 4/1/2023. An initial assessment was documented on 11/16/2022. RN #1 documented a reassessment on 1/14/2023, but then later stated that the patient has not received any skilled nursing visits in 2023. There was no documentation of a review of the patient ' s medications. There was no documentation that the physician was provided a written summary of the patient ' s current status or services being provided at least every sixty (60) days. There were no skilled nursing visits documented for the certification period. RN #1 stated that this patient is " inactive " at the request of the family, with no date provided. There was no documentation that the attending physician was notified that the patient has not been seen in 2023.
An interview conducted with RN #1 on 2/15/2023 at approximately 12:00 P.M. revealed that " most of the patients are seen weekly " by RN #1. RN #1 stated that a nursing visit form is not completed with each visit. Most of the time a note is entered in the communication notes that the patient was seen by the RN. RN #1 stated, " the review of the 485 is the documentation of the reassessment visit. " RN #1 confirmed the above findings.
Plan of Correction:1. The RN will initiate the plan of treatment and necessary revisions, document review of the patient ' s medications (side effects, adverse reactions, and possible interactions with other medications) at least every 60 days, document regular assessments/reassessments to evaluate the patient's nursing needs, prepare clinical progress notes, and/or ensure physician ' s orders were signed in accordance with agency policy C280. All medications profiles and plan of care will be updated per policy C280, D100, D125.
2. All clients are affected by this deficiency
3. Nurses will be trained on policy C280, D100 and D125 (Medication Management)
4. All clinical records will be reviewed and audited every 60 days at the time of certification or re-certification by both the Nurse and administrator. Clinical records will also be reviewed during quarterly quality reviews.
5. corrective action complete by 04/16/2023
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 review of agency policy, clinical records (CR) and interview with Registered Nurse (RN) #1, the agency failed to maintain a clinical record in accordance with agency policy for five (5) of five (5) CR reviewed. (CR #1, 2, 3, 4, and 5).
Findings include:
A review of policy #C190 titled " Clinical Record Content " on 2/15/2023 at approximately 12:15 P.M. stated, " Policy: All clinical records will be maintained for every client receiving home care services in accordance with state law and Agency policy ... Procedure: 3. The clinical record shall contain appropriate identifying information, including, but not limited to: Intake referral form, including referral source ... Admission and discharge dates from a hospital or other institution, if applicable, home service agreement ... comprehensive assessments ... Physician ' s orders ... Signed and dated clinical progress notes of all direct care staff providing client care ... Client response to care/services provided ... Physician summary reports, Visit Schedule/Frequency, Transfer and Discharge Summaries, as applicable. "
A review of clinical records on 2/15/ 2023, from approximately 11:00 A.M. to 12:00 P.M. revealed the following:
CR #1, start of care 11/14/2022, certification period reviewed 1/8/2023 to 3/8/2023. The CR contained no documentation of a referral date or source. There was no documention of a consent for skilled home health services. An initial assessment was documented on 11/8/2022. There was no documentation of a reassessment of the patient within five (5) days of the end of the previous certification period. Only one (1) clinical progress note was documented by RN #1 for the certification period reviewed on 1/27/2023. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services at least every sixty (60) days.
CR #2, start of care 11/10/2022, certification period reviewed 1/8/2023 to 3/8/2023. The CR contained no documentation of a referral date or source. There was no documention of a consent for skilled home health services. An initial assessment was documented on 11/11/2022. There was no documentation of a reassessment of the patient within five (5) days of the end of the previous certification period. The patient was identified by RN #1 as being hospitalized from 1/8/2023 through 1/27/2023. There was no documentation of a transfer summary, notification of the attending physician, or a verbal order to hold or resume services. RN #1 stated that a skilled nursing visit was conducted on 2/10/2023, but no documentation was present in the CR. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services at least every sixty (60) days.
CR #3, start of care 9/12/2022, certification period reviewed 1/8/2023 to 3/8/2023. The CR contained no documentation of a referral date or source. There was no documention of a consent for skilled home health services An initial assessment was documented on 9/9/2022. A reassessment was documented on 11/7/2022. There was no documentation of a reassessment of the patient within five (5) days of the end of the previous certification period. There were no skilled nursing visits documented for the certification period. RN #1 documented visits on 1/19/2023, 1/27/2023, and 2/10/2023 in communication notes. There was no documentation of a skilled nursing assessment completed on the dates noted. There was no documentation that the physician was provided a written summary of the patient ' s current status and services at least every sixty (60) days.
CR #4, start of care 6/15/2022, certification period reviewed 11/28/22 to 1/26/2023. The CR contained no documentation of a referral date or source. There was no documention of a consent for skilled home health services. An initial assessment documented on 11/16/2022. A reassessment was documented on 1/14/2023. A skilled nursing visit was documented on 12/22/2022, by RN #1. The patient was identified by RN #1 as being discharged to a skilled nursing facility on 1/23/2023. There was no documentation of a discharge summary, a transfer summary or notification of the attending physician. There was no documentation that the physician was provided a written summary of the patient ' s current status and the services being provided at least every sixty (60) days.
CR #5, start of care 6/13/2022, certification period reviewed 2/1/2023 to 4/1/2023. The CR contained no documentation of a referral date or source. There was no documention of a consent for skilled home health services. An initial assessment was documented on 11/16/2022. There was no documentation of a reassessment of the patient within five (5) days of the end of the previous certification period. RN #1 documented a reassessment in a communication note dated 1/14/2023, but then later stated that the patient has not received any skilled nursing visits in 2023. There were no skilled nursing visits documented for the certification period. RN #1 stated that this patient is " inactive " at the request of the family, with no date provided. There was no documentation that the physician was provided a written summary of the patient ' s current status or services being provided at least every sixty (60) days. There was no documentation that the attending physician was notified that the patient has not been seen in 2023, and no orders to hold services or discharge the patient.
An interview conducted with RN #1 on 2/15/2023 at approximately 12:00 P.M. revealed that " most of the patients are seen weekly " by RN #1. RN #1 stated that a nursing visit form is not completed with each visit. Most of the time a note is entered in the communication notes that the patient was seen by the RN. RN #1 stated, " the review of the 485 is the documentation of the reassessment visit. " RN#1 stated "we use the consents from when the patient started with our non medical home care license." RN #1 confirmed the above findings.
Plan of Correction: 1. The RN will review all client records according to policy clinical record content. Clinical records will updated according to the policy C190. Policy requires appropriate identifying information including by not limited to:
referrals, skilled consents, assessments, orders, progress notes, transfer summary, 60 day summary, resumption of care orders, etc.
2. All clients are affected by this deficiency
3. Nurses will be trained on policy clinical record content. Nurse onboarding and training will be updated to ensure these topics are covered.
4. All clinical records will be reviewed and audited every 60 days at the time of certification or re-certification by both the Nurse and administrator. Clinical records will also be reviewed during quarterly quality reviews.
5. corrective action complete by 04/16/2023
Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey concluded on February 16, 2023, Comforcare Home Care- Chester County South, 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 onsite home health agency state re-licensure survey concluded on February 16, 2023, Comforcare Home Care- Chester County South, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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