Initial Comments:
Based on the findings of an onsite unannounced home health agency Initial Medicare Certification survey conducted January 24, 2024, January 25, 2024, and concluded offsite on January 31, 2024, Edna's Care, LLC., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.50(c)(5) ELEMENT
Receive all services in plan of care
Name - Component - 00
Receive all services outlined in the plan of care.
Observations:
Based on a review of clinical records (CR), personnel files (PF), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to provide all services according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will contact the physician overseeing the plan of care for CR#2, 4, 6 & 7 to notify that those patients did not receive all services outlined in the referral to start home health services and will update the medical records according to orders received for the action.
The Director of Nursing will verbally notify the patients for CR#2, 4, 6 & 7 of their right to receive all services outlined in the plan of care. Documentation will be entered into the medical record for this action.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will audit 100% of clinical records within 30 days to ensure that 484.50(c)(7); G436 is compliant, that the patient has received all services outlined in the plan of care. Threshold is 100%. If threshold is not met, the Director of Nursing will contact the physician overseeing the plan of care to notify that those patients did not receive all services outlined in the referral to start home health services and will update the medical records according to orders received for the action. The Director of Nursing will also verbally notify the patients whose records were out of compliance of their right to receive all services outlined in the plan of care. Documentation will be entered into the medical record for this action.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Director of Nursing will educate all staff on element 484.50(c)(7); G436, that the patient has the right to receive all services outlined in the plan of care.
Staff will verbalize understanding.
The Director of Nursing will review 100% of referrals upon receiving to ensure all services outlined in the plan of care can be provided to the patient and will inform the physician ordering if the services cannot be provided. The patient will not be accepted for services and/or the medical record will be updated, as needed with verbal orders. The documentation of the outcome will also be recorded on the referral log.
4. Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all clinical records monthly for 3 months to ensure that 484.50(c)(7); G436 is compliant, that the patient has received all services outlined in the plan of care. Threshold is 100%. If evidence of compliance cannot be obtained then Director of Nursing or delegated representative will notify the physician and the patient, then document communication in the medical records of the outcome. The Director of Nursing will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
484.55(a)(1) ELEMENT
RN performs assessment
Name - Component - 00
A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date.
Observations:
Based on a review of agency policy, clinical records (CR) and an interview with the administrator and alternate director of nursing, the agency failed to ensure that the initial assessment visit was held within 48 hours of the referral for three (3) of seven (7) CR's reviewed: CR#1, 4 &; 7.
Findings include:
A review of the agency's policies was conducted on January 25, 2023, at approximately 1:00PM and revealed the following:
Policy titled, "5.3 Patient Assessments/Plan of Care" stated, "An initial assessment visit is completed by a registered nurse, to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment is conducted: within 48 hours of referral or within 48 hours of the patient's return home, or on the physician-ordered start-of-care date..."
A review of clinical records was conducted on January 25, 2023, at approximately 9:30 AM and January 31, 2023, at approximately 8:00AM.
CR#1. Start of Care: 11/1/23. Certification period reviewed: 11/1/23 through 12/30/23. File contained a physician referral form dated 10/23/23. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 11/1/23 which is greater than forty-eight (48) hours after the referral date.
CR#4. Start of Care: 11/28/23. Certification period reviewed: 11/28/23 through 1/26/24. File contained a physician referral form dated 11/22/23. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 11/28/23 which is greater than forty-eight (48) hours after the referral date.
CR#7. Start of Care: 12/5/23. Certification period reviewed: 12/5/23-2/2/24. File contained a physician referral form dated 11/21/23. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 12/5/23 which is greater than forty-eight (48) hours after the referral date.
An interview conducted with the administrator and alternate director of nursing on January 25, 2023, at approximately 2:00PM confirmed the above findings.
Plan of Correction:1) Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will educate all staff on the element 484.55(a)(1); G514, the initial assessment is conducted:
1. Within 48 hours of referral; or
2. Within 48 hours of the patient's return home; or
3. On the physician or allowed practitioner ordered start-of-care date.
Staff will verbalize understanding.
2) How the facility will act to protect patients in similar situations
The Director of Nursing will educate all staff on the element 484.55(a)(1); G514, the initial assessment is conducted:
1. Within 48 hours of referral; or
2. Within 48 hours of the patient's return home; or
3. On the physician or allowed practitioner ordered start-of-care date.
Staff will verbalize understanding.
3) Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The referral log will be monitored daily by the Director of Nursing to ensure compliance with 484.55(a)(1); G514, The Director of Nursing will educate all staff on the element 484.55(a)(1); G514, the initial assessment is conducted:
1. Within 48 hours of referral; or
2. Within 48 hours of the patient's return home; or
3. On the physician or allowed practitioner ordered start-of-care date.
The Director of Nursing will care coordinate with the clinician at the time of referral acceptance and the visit will be scheduled. Then, the Director of Nursing will receive report on the day of the initial assessment from that clinician to ensure timely initiation of care.
The referral log will be monitored by the Director of Nursing and updated daily to ensure compliance with 484.55(a)(1).
4) Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all medical records monthly for 3 months to ensure that 484.55(a)(1) is compliant. Threshold is 98%. If evidence of compliance cannot be obtained then the Director of Nursing will re-educate staff. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
484.60(b) STANDARD
Conformance with physician orders
Name - Component - 00
Standard: Conformance with physician or allowed practitioner orders.
Observations:
Based on a review of clinical records (CR), personnel files (PF), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to provide care according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1) Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will contact the physician overseeing the plan of care for CR#2, 4, 6 & 7 to notify that those patients did not receive all services outlined in the referral to start home health services and will update the medical records according to orders received for the action.
2) How the facility will act to protect patients in similar situations
The Director of Nursing will audit 100% of medical records within 30 days to ensure that 484.60(b); G578 is compliant, that services are provided in conformance with physician or allowed practitioner orders. Threshold is 100%. If threshold is not met, the Director of Nursing will contact the physician overseeing the plan of care to notify that those patients did not receive all services outlined in the referral to start home health services and did not incorporate orders into the plan of care. The Director of Nursing will update the medical records according to orders received for the action.
3) Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Director of Nursing will educate all staff on element 484.60(b); G578, that services are provided in conformance with physician or allowed practitioner orders
The Director of Nursing will review 100% of referrals and to ensure all services outlined in the plan of care can be provided to the patient and will inform the physician ordering if the services cannot be provided. The patient will not be accepted for services and/or the medical record will be updated, as needed with verbal orders.
4) Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all clinical records monthly for 3 months to ensure that 484.60(b); G578 is compliant, that services are provided in conformance with physician or allowed practitioner orders. Threshold is 100%. If evidence of compliance cannot be obtained then Director of Nursing or delegated representative will notify the physician and will update the medical records according to orders received for the action. The Director of Nursing will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
484.105(a) STANDARD
Governing body
Name - Component - 00
Standard: Governing body.
A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the administrator and alternate director of nursing, the agency's Governing Body failed to provide overall management for the agency as evidenced by not providing all services according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7), the agency failed to ensure a qualified physical therapist or occupational therapist was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed (CR#3).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
Job Description for "Registered Physical Therapist" stated, "Qualifications: successful completion of a Physical Therapy education program...Must be licensed, or registered by the State of Pennsylvania..."
Policy titled "PA Specific: Therapy Services" stated, "Physical Therapy...the organization shall provide Physical Therapy services, by qualified licensed Physical Therapists..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings. The Administrator confirmed Physical Therapy was an offered service, but PF#3 has not seen any patients.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will educate The Governing Body in a meeting on 484.105(a), that the governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.
Members will verbalize understanding and meeting minutes will be documented and filed in the meeting minutes binder.
2. How the facility will act to protect patients in similar situations
The Governing Body (or designated persons so functioning) will assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Governing Body will conduct at least an annual meeting to review the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.
Meeting minutes will be documented and filed in the meeting minutes binder.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will perform bi-annual audits on The Governing Body activities for a period of 1 year to ensure that The Governing Body activities include the following:
A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.
Threshold is 100%. If non-compliance is noted, the Administrator will re-educate members on the requirements of 484.105(a). Once threshold is met, Annual Program Evaluation will resume.
484.105(b)(1)(iv) ELEMENT
Ensure that HHA employs qualified personnel
Name - Component - 00
(iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the administrator and alternate director of nursing, the agency's failed to follow their personnel policies as evidenced by the following not being documented in the personnel files:
An initial competency evaluation for two (2) of six (6) PFs reviewed (PF# 4 &; 5) and
An FBI Criminal Background Check for one (1) of six (6) PFs reviewed (PF #4) and
Complete Tuberculosis (TB) testing as required for two (2) of six (6) PFs reviewed (PF# 4 &; 5).
and the agency accepted patients for physical therapy and occupational therapy without having a qualified Physical Therapist or Occupational Therapist for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17)
Policy titled, "4.7 Background, Sex Offenders, and OIG Checks" states, "The agency requires all applicants to submit with their applications and requires all administrators and any operator who have or may have direct contact with a client to submit the following information obtained within the preceding one-year period...when the applicant is not, and for the two years immediately preceding the date of application has not been, a resident of Pennsylvania, the agency requires the applicant to submit with the application for employment a report of Federal criminal history record information...the state of Pennsylvania shall submit the fingerprints to the Federal Bureau of Investigation for a national criminal history check."
Policy titled, "4.2 Required Information" stated, "Personnel file components...Health Information which is acquired prior to referral to the patient for all staff with direct patient contact...initial and annual TB screening requirements, TB results...for direct care staff, skills competencies checklist...annual observation of job duties..."
Policy titled, "TB Testing/Screening" stated, "Upon Hire all direct care staff, including contract staff, will receive a baseline TB screening using a TST or a single BAMT (blood test) ...There are two types of testing for TB in health care workers: Initial baseline testing upon hire: two-step testing with TB skin test or a TB blood test..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
PF#4. Date of Hire: 1/1/23. File did not contain any documentation of initial competency completed. File contained a Delaware State Driver's License that was issued on 12/10/19 and a Delaware address that was listed on the employment application. File did not contain an FBI Criminal Background Check. File contained a TST completed on 9/14/23 but did not contain the second step of the initial TST.
PF#5. Date of Hire: 1/1/23. File did not contain any documentation of initial competency completed. File contained a TST completed on 2/6/23 but did not contain the second step of the initial TST.
PF#6. Date of Hire: 1/25/19. File did not contain annual observation of job duties for 2023.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will have the Director of Nursing complete competency evaluations for PF#4 and PF#5 and update the files with this documentation.
The Administrator will complete a FBI Criminal Background Check and obtain an updated address for PF#4.
The Administrator updated PF#4 with a negative result of the second step for the TST.
The Administrator updated PF#5 with QuantiFERON-TB Gold Plus negative result.
The Administrator will terminate employment with the employee that belongs to PF#3 due to not meeting licensing requirements as a Physical Therapist.
The Administrator will update PF#6 with an annual observation of job duties, once conducted.
2. How the facility will act to protect patients in similar situations
The Administrator will audit 100% of personnel files within the next 30 days to ensure that the HHA employs qualified personnel, including assuring the personnel policies and procedures are followed. If non-compliance is noted during audits, staff will not be allowed to accept assignments until compliance is achieved.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Governing Body will educate HR staff that the Administrator must ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.
HR staff will verbalize understanding.
The Administrator will audit 100% of new hire personnel files within the first 30 days of employment to ensure that qualifications and policies are procedures are followed and field staff will not be allowed to accept assignments until files are 100% compliant.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of all personnel files monthly for 3 months to ensure that 484.105(b)(1)(iv), to ensure that the HHA employs qualified personnel, including assuring the personnel policies and procedures are followed. Threshold is 100%. If evidence of compliance cannot be obtained then the Administrator will ensure that staff will not be allowed to accept assignments until compliance is achieved. The Administrator will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 100% of personnel files annually and within 30 days of hire.
The Administrator will monitor the audits and education findings and will report results to the Governing Board to identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
484.105(e)(3) ELEMENT
Primary HHA is responsible for patient care
Name - Component - 00
The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients.
Observations:
Based on a review of clinical records (CR), personnel files (PF), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to conduct and provide, either directly or under arrangements, all services rendered to patients for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will ensure the HHA is responsible for patient care, and will conduct and provide, either directly or under arrangements, all services required to CR#2, 4, 6 & 7. If the agency is unable to provide required services to these patients, per MD order, the agency will offer to transfer to another HHA that is willing and able to provide the needed services, as per policy.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will educate the Director of Nursing on 484.105(e)(3), that the primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients.
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
4. Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all clinical records monthly for 3 months to ensure that 484.105(e)(3) is compliant, that the primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. Threshold is 100%. If evidence of compliance cannot be obtained then Director of Nursing or delegated representative will notify the physician and the patient, then document communication in the medical records of the outcome. The Director of Nursing will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
484.105(g) STANDARD
Outpatient therapy services
Name - Component - 00
Standard: Outpatient physical therapy or speech-language pathology services.
An HHA that furnishes outpatient physical therapy or speech-language pathology services must meet all of the applicable conditions of this part and the additional health and safety requirements set forth in §485.711, §485.713, §485.715, §485.719, §485.723, and §485.727 of this chapter to implement section 1861(p) of the Act.
Observations:
Based on a review of personnel files (PF), policy and procedures, and an interview with the agency's administrator and alternate director of nursing, it was determined the agency failed to ensure a qualified physical therapist was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed. PF #3
Findings include:
Review of the agency's policy occurred on 1/25/24 at approximately 12:00 PM and revealed the following:
Job Description for "Registered Physical Therapist" stated, "Qualifications: successful completion of a Physical Therapy education program...Must be licensed, or registered by the State of Pennsylvania..."
Policy titled "PA Specific: Therapy Services" stated, "Physical Therapy...the organization shall provide Physical Therapy services, by qualified licensed Physical Therapists..."
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
An interview with the agency's administrator on 1/25/24 at approximately 12:30PM confirmed the above findings. The Administrator confirmed Physical Therapy was an offered service, but PF#3 has not seen any patients.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will educate the Director of Nursing on 484.105(g) Outpatient physical therapy or speech-language pathology services, an HHA that furnishes outpatient physical therapy or speech-language pathology services must meet all of the applicable conditions of this part and the additional health and safety requirements set forth in § 485.711, § 485.713, § 485.715, § 485.719, § 485.723, and § 485.727 of this chapter to implement section 1861(p) of the Act.
The Administrator will hire all services that the agency furnishes, either directly or under arrangement within 30 days and will not accept referrals until qualified clinicians are ready to accept assignments.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of all personnel files monthly for 3 months to ensure that 484.105(g) Outpatient physical therapy or speech-language pathology services, an HHA that furnishes outpatient physical therapy or speech-language pathology services must meet all of the applicable conditions of this part and the additional health and safety requirements set forth in § 485.711, § 485.713, § 485.715, § 485.719, § 485.723, and § 485.727 of this chapter to implement section 1861(p) of the Act is met. Threshold is 100%. Once threshold is met for 3 months in a row, may continue with auditing 100% of personnel files annually and within 30 days of hire.
The Administrator will monitor the audits and education findings and will report results to the Governing Board to identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
484.115(h) STANDARD
Physical Therapist
Name - Component - 00
Standard: Physical therapist.
A person who is licensed, if applicable, by the state in which practicing, unless licensure does not apply and meets one of the following requirements:
(1)(i) Graduated after successful completion of a physical therapist education program approved by one of the following:
(A) The Commission on Accreditation in Physical Therapy Education (CAPTE).
(B) Successor organizations of CAPTE.
(C) An education program outside the United States determined to be substantially equivalent to physical therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR 212.15(e) as it relates to physical therapists.
(ii) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
(2) On or before December 31, 2009-
(i) Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or
(ii) Meets both of the following:
(A) Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR 212.15(e) as it relates to physical therapists.
(B) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
(3) Before January 1, 2008 graduated from a physical therapy curriculum approved by one of the following:
(i) The American Physical Therapy Association.
(ii) The Committee on Allied Health Education and Accreditation of the American Medical Association.
(iii) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association.
(4) On or before December 31, 1977 was licensed or qualified as a physical therapist and meets both of the following:
(i) Has 2 years of appropriate experience as a physical therapist.
(ii) Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.
(5) Before January 1, 1966-
(i) Was admitted to membership by the American Physical Therapy Association;
(ii) Was admitted to registration by the American Registry of Physical Therapists;or
(iii) Graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education.
(6) Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of fulltime experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy.
(7) If trained outside the United States before January 1, 2008, meets the following requirements:
(i) Was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy.
(ii) Meets the requirements for membership in a member organization of the World Confederation for Physical Therapy.
Observations:
Based on a review of clinical records (CR) and personnel files (PF), policy and procedures, and an interview with the agency's administrator and alternate director of nursing, it was determined the agency failed to ensure the physical therapist was licensed and qualified for one (1) of six (6) personnel files reviewed (PF#3).
Findings include:
Review of the agency's policy occurred on 1/25/24 at approximately 12:00 PM and revealed the following:
Job Description for "Registered Physical Therapist" stated, "Qualifications: successful completion of a Physical Therapy education program...Must be licensed, or registered by the State of Pennsylvania..."
Policy titled "PA Specific: Therapy Services" stated, "Physical Therapy...the organization shall provide Physical Therapy services, by qualified licensed Physical Therapists..."
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
An interview with the agency's administrator on 1/25/24 at approximately 12:30PM confirmed the above findings. The Administrator confirmed Physical Therapy was an offered service, but PF#3 has not seen any patients.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will terminate employment with the employee that belongs to PF#3 due to not meeting licensing requirements as a Physical Therapist.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will educate HR staff on standard 484.115(h) Physical Therapist: A person who is licensed, if applicable, by the state in which practicing, unless licensure does not apply and meets one of the following requirements:
(1)(i) Graduated after successful completion of a physical therapist education program approved by one of the following:
(A) The Commission on Accreditation in Physical Therapy Education (CAPTE).
(B) Successor organizations of CAPTE.
(C) An education program outside the United States determined to be substantially equivalent to physical therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR 212.15(e) as it relates to physical therapists.
(ii) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
(2) On or before December 31, 2009—
(i) Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or
(ii) Meets both of the following:
(A) Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR 212.15(e) as it relates to physical therapists.
(B) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
(3) Before January 1, 2008 graduated from a physical therapy curriculum approved by one of the following:
(i) The American Physical Therapy Association.
(ii) The Committee on Allied Health Education and Accreditation of the American Medical Association.
(iii) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association.
(4) On or before December 31, 1977 was licensed or qualified as a physical therapist and meets both of the following:
(i) Has 2 years of appropriate experience as a physical therapist.
(ii) Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.
(5) Before January 1, 1966—
(i) Was admitted to membership by the American Physical Therapy Association;
(ii) Was admitted to registration by the American Registry of Physical Therapists; or
(iii) Graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education.
(6) Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of fulltime experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy.
(7) If trained outside the United States before January 1, 2008, meets the following requirements:
(i) Was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy.
(ii) Meets the requirements for membership in a member organization of the World Confederation for Physical Therapy.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of all personnel files monthly for 3 months to ensure that 484.115(h) is met. Threshold is 100%. Once threshold is met for 3 months in a row, may continue with auditing 100% of personnel files annually and within 30 days of hire.
The Administrator will monitor the audits and education findings and will report results to the Governing Board to identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
Initial Comments:Based on the findings of an onsite unannounced Medicare Initial Certification survey conducted January 24, 2024, January 25, 2024, and concluded offsite on January 31, 2024, Edna's Care, LLC., was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted January 24, 2024, January 25, 2024, and concluded offsite on January 31, 2024, Edna's 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(b) REQUIREMENT
SERVICES PROVIDED
Name - Component - 00
601.21(b) Services Provided. Part-time or intermittent skilled nursing services and at least one
other therapeutic service-physical therapy, occupational therapy, speech pathology,
medical social services or home health aides-shall be made available on a visiting basis,
in a place of residence used as a patient ' s home. A Home Health Care Agency shall
provide at least one of the qualifying services directly through agency employees, but
may provide, by written contract, the second qualifying service and additional services
under arrangements with another agency or organization.
Observations:
Based on a review of clinical records (CR), personnel files (PF), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to provide all services according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7) and the agency failed to ensure a qualified physical therapist or occupational therapist was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed (PF#3)
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will hire all services that the agency furnishes, either directly or under arrangement within 30 days and will not accept referrals until qualified clinicians are ready to accept assignments.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will educate all HR staff on 601.21(b) Services Provided: Part-time or intermittent skilled nursing services and at least one other therapeutic service-physical therapy, occupational therapy, speech pathology, medical social services or home health aides-shall be made available on a visiting basis, in a place of residence used as a patient's home. A Home Health Care Agency shall provide at least one of the qualifying services directly through agency employees, but may provide, by written contract, the second qualifying service and additional services under arrangements with another agency or organization.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of all personnel files monthly for 3 months to ensure that 601.21(b) services provided is met. Threshold is 100%. Once threshold is met for 3 months in a row, may continue with auditing 100% of personnel files annually and within 30 days of hire.
The Administrator will monitor the audits and education findings and will report results to the Governing Board to identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
601.21(c) REQUIREMENT
GOVERNING BODY
Name - Component - 00
601.21(c) Governing Body. A governing
body (or designated persons so
functioning) assumes full legal
authority and responsibility for the
operation of the agency. The
governing body appoints: (i) a
qualified administrator, (ii) arranges
for professional service, (iii) adopts
and periodically reviews written
bylaws or an acceptable equivalent,
and (iv) oversees the management and
fiscal affairs of the agency. The
name and address of each officer,
director, and owner are disclosed to
the State agency with changes reported
promptly.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the administrator and alternate director of nursing, the agency's Governing Body failed to provide overall management for the agency as evidenced by not providing care according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7) and the agency failed to ensure a qualified physical therapist or occupational therapist that was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed (PF#3)
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
Job Description for "Registered Physical Therapist" stated, "Qualifications: successful completion of a Physical Therapy education program...Must be licensed, or registered by the State of Pennsylvania..."
Policy titled "PA Specific: Therapy Services" stated, "Physical Therapy...the organization shall provide Physical Therapy services, by qualified licensed Physical Therapists..."
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will educate The Governing Body in a meeting on 601.21(c), that the governing body (or designated persons so functioning) assumes full legal authority and responsibility for the operation of the agency. The governing body appoints:
(i) a qualified administrator,
(ii) arranges for professional service,
(iii) adopts and periodically reviews written by laws or an acceptable equivalent, and
(iv) oversees the management and fiscal affairs of the agency. The name and address of each officer, director, and owner are disclosed to the State agency with changes reported promptly.
Members will verbalize understanding and meeting minutes will be documented and filed in the meeting minutes binder.
2. How the facility will act to protect patients in similar situations
The Governing Body (or designated persons so functioning) will assume full legal authority and responsibility for the operation of the agency. The governing body will appoint: (i) a qualified administrator, (ii) arrange for professional service,
(iii) adopt and periodically review written by laws or an acceptable equivalent, and (iv) will oversee the management and fiscal affairs of the agency. The name and address of each officer, director, and owner will be disclosed to the State agency with changes reported promptly.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will conduct a Governing Body meeting, at least annually to review and appoint professional services, adopt and periodically review written by laws or an acceptable equivalent, and to oversee the management and fiscal affairs of the agency.
Meeting minutes will be documented and filed in the meeting minutes binder.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will perform bi-annual audits on The Governing Body activities for a period of 1 year to ensure that The Governing Body activities include the following:
The governing body (or designated persons so functioning) assumes full legal authority and responsibility for the operation of the agency. The governing body appoints:
(i) a qualified administrator,
(ii) arranges for professional service,
(iii) adopts and periodically reviews written by laws or an acceptable equivalent, and
(iv) oversees the management and fiscal affairs of the agency. The name and address of each officer, director, and owner are disclosed to the State agency with changes reported promptly.
Threshold is 100%. If non-compliance is noted, the Administrator will re-educate members on the requirements of 601.21(c). Once threshold is met, Annual Program Evaluation will resume.
601.21(d) REQUIREMENT
ADMINISTRATOR
Name - Component - 00
601.21(d) Administrator. The
qualified administrator, who may also
be the supervising physician or
registered nurse: (i) organizes and
directs the agency's ongoing
functions, (ii) maintains ongoing
liaison among the governing body, the
group of professional personnel, and
the staff, (iii) employs qualified
personnel and ensures adequate staff
education and evaluations, (iv)
ensures the accuracy of public
information materials and activities,
and (v) implements an effective
budgeting and accounting system. A
qualified person is authorized in
writing to act in the absence of the
administrator.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the administrator and alternate director of nursing, the agency's administrator failed to organize and direct the agency's ongoing functions as evidenced by not providing care according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7) and having incomplete personnel files without the following documented: An initial competency evaluation for two (2) of five (5) PFs reviewed (PF# 4 &; 5) and the agency failed to ensure a qualified physical therapist or occupational therapist that was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed (PF#3)
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
Job Description for "Registered Physical Therapist" stated, "Qualifications: successful completion of a Physical Therapy education program...Must be licensed, or registered by the State of Pennsylvania..."
Policy titled "PA Specific: Therapy Services" stated, "Physical Therapy...the organization shall provide Physical Therapy services, by qualified licensed Physical Therapists..."
Policy titled, "4.2 Required Information" stated, "Personnel file components...Health Information which is acquired prior to referral to the patient for all staff with direct patient contact...initial and annual TB screening requirements, TB results...for direct care staff, skills competencies checklist...annual observation of job duties..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
PF#4. Date of Hire: 1/1/23. File did not contain any documentation of initial competency completed.
PF#5. Date of Hire: 1/1/23. File did not contain any documentation of initial competency completed.
PF#6. Date of Hire: 1/25/19. File did not contain annual observation of job duties for 2023.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Governing Body will educate Administrator on the requirement at 601.21(d) that the qualified administrator, who may also be the supervising physician or registered nurse: (i) organizes and directs the agency's ongoing functions, (ii) maintains on going liaison among the governing body, the group of professional personnel, and the staff, (iii)employs qualified personnel and ensures adequate staff education and evaluations, (iv) ensures the accuracy of public information materials and activities, and (v)implements an effective budgeting and accounting system. A qualified person is authorized in writing to act in the absence of the administrator.
The Administrator will verbalize understanding.
2. How the facility will act to protect patients in similar situations
The qualified Administrator will (i) organize and direct the agency's ongoing functions, (ii) maintain on going liaison among the governing body, the group of professional personnel, and the staff, (iii) employ qualified personnel and ensures adequate staff education and evaluations, (iv) ensure the accuracy of public information materials and activities, and (v) implement an effective budgeting and accounting system and ensure a qualified person is authorized in writing to act in the absence of the administrator.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Governing Body will annually review the Administrator on performance with: (i) organizing and directing the agency's ongoing functions, (ii) maintaining on going liaison among the governing body, the group of professional personnel, and the staff, (iii) employing qualified personnel and ensuring adequate staff education and evaluations, (iv) ensuring the accuracy of public information materials and activities, and (v) implementing an effective budgeting and accounting system and ensuring a qualified person is authorized in writing to act in the absence of the administrator.
The performance evaluation will be documented in the Administrator's personnel file.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator's personnel file will be audited annually to ensure requirements are met for 601.21(d)
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 clinical records (CR), agency policy, and an interview with the administrator and alternate director of nursing, the agency's failed to follow their personnel policies as evidenced by the following not being documented in the personnel files (PF):
An initial competency evaluation for two (2) of six (6) PFs reviewed (PF# 4 &; 5) and
An FBI Criminal Background Check for one (1) of six (6) PFs reviewed (PF #4) and
Complete Tuberculosis (TB) testing as required for two (2) of six (6) PFs reviewed (PF# 4 &; 5).
and the agency accepted patients for physical therapy and occupational therapy without having a qualified Physical Therapist or Occupational Therapist for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7),
and the agency failed to ensure a qualified physical therapist or occupational therapist was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed (PF#3)
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17)
Policy titled, "4.7 Background, Sex Offenders, and OIG Checks" states, "The agency requires all applicants to submit with their applications and requires all administrators and any operator who have or may have direct contact with a client to submit the following information obtained within the preceding one-year period...when the applicant is not, and for the two years immediately preceding the date of application has not been, a resident of Pennsylvania, the agency requires the applicant to submit with the application for employment a report of Federal criminal history record information...the state of Pennsylvania shall submit the fingerprints to the Federal Bureau of Investigation for a national criminal history check."
Policy titled, "4.2 Required Information" stated, "Personnel file components...Health Information which is acquired prior to referral to the patient for all staff with direct patient contact...initial and annual TB screening requirements, TB results...for direct care staff, skills competencies checklist...annual observation of job duties..."
Policy titled, "TB Testing/Screening" stated, "Upon Hire all direct care staff, including contract staff, will receive a baseline TB screening using a TST or a single BAMT (blood test) ...There are two types of testing for TB in health care workers: Initial baseline testing upon hire: two-step testing with TB skin test or a TB blood test..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
PF#4. Date of Hire: 1/1/23. File did not contain any documentation of initial competency completed. File contained a Delaware State Driver's License that was issued on 12/10/19 and a Delaware address that was listed on the employment application. File did not contain an FBI Criminal Background Check. File contained a TST completed on 9/14/23 but did not contain the second step of the initial TST.
PF#5. Date of Hire: 1/1/23. File did not contain any documentation of initial competency completed. File contained a TST completed on 2/6/23 but did not contain the second step of the initial TST.
PF#6. Date of Hire: 1/25/19. File did not contain annual observation of job duties for 2023.
A review of personnel files revealed no evidence of a qualified Physical Therapist or a qualified Occupational Therapist.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will have the Director of Nursing complete competency evaluations for PF#4 and PF#5 and update the files with this documentation.
The Administrator will complete a FBI Criminal Background Check and obtain an updated address for PF#4.
The Administrator updated PF#4 with a negative result of the second step for the TST.
The Administrator updated PF#5 with QuantiFERON-TB Gold Plus negative result.
The Administrator will terminate employment with the employee that belongs to PF#3 due to not meeting licensing requirements as a Physical Therapist.
The Administrator will update PF#6 with an annual observation of job duties, once conducted.
2. How the facility will act to protect patients in similar situations
The Administrator will audit 100% of personnel files within the next 30 days to ensure that personnel records include qualifications, licensure, performance evaluations, health examinations, documentation of orientation provided, and job descriptions, and are kept current. If non-compliance is noted during audits, staff will not be allowed to accept assignments until compliance is achieved.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will educate HR staff on the requirements of 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.
Staff will verbalize understanding.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of all personnel files monthly for 3 months on 601.21(f), to ensure that 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. Threshold is 100%. If evidence of compliance cannot be obtained, then the Administrator will ensure that staff will not be allowed to accept assignments until compliance is achieved. The Administrator will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 100% of personnel files annually and within 30 days of hire.
The Administrator will monitor the audits and education findings and will report results to the Governing Board to identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
601.31(a) REQUIREMENT
PATIENT ACCEPTANCE
Name - Component - 00
601.31(a) Patient Acceptance.
Patients are accepted for treatment on
the basis of a reasonable expectation
that the patient's medical, nursing
and social needs can be met adequately
by the agency in the patient's place
of residence. Care follows a written
plan of treatment established and
periodically reviewed by a physician
and care continues under the general
supervision of a physician.
Observations:
Based on a review of clinical records (CR), personnel files (PF), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to accept patients on the reasonable expectation that treatment needs would be adequately met in their place of residence. The agency accepted patients for physical therapy and occupational therapy that was not provided by the agency for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will contact the physician overseeing the plan of care for CR#2, 4, 6 & 7 to notify that those patients did not receive all services outlined in the referral to start home health services and will update the medical records according to orders received for the action. If the agency is unable to provide required services to these patients, per MD order, the agency will offer to transfer to another HHA that is willing and able to provide the needed services, as per policy.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will audit 100% of medical records within 30 days to ensure that 601.31(a), that patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of treatment established and periodically reviewed by a physician and care continues under the general supervision of a physician. Threshold is 100%. If threshold is not met, the Director of Nursing will contact the physician overseeing the plan of care to notify that those patients did not receive all services outlined in the referral to start home health services and did not incorporate orders into the plan of care. The Director of Nursing will update the medical records according to orders received for the action.
The Director of Nursing will review 100% of referrals and to ensure all services outlined in the plan of care can be provided to the patient and will inform the physician ordering if the services cannot be provided. The patient will not be accepted for services and/or the medical record will be updated, as needed with verbal orders.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Director of Nursing will educate staff of the requirement at 601.31(a), Patient Acceptance: Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of treatment established and periodically reviewed by a physician and care continues under the general supervision of a physician.
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
4. Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all medical records monthly for 3 months to ensure that 601.31(a) is compliant, that patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of treatment established and periodically reviewed by a physician and care continues under the general supervision of a physician. Threshold is 100%. If evidence of compliance cannot be obtained then the Director of Nursing or delegated representative will notify the physician and will update the medical records according to orders received for the action. The Director of Nursing will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
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 clinical records (CR), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to provide all services according to the physician orders/plan of treatment (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will contact the physician overseeing the plan of care for CR#2, 4, 6 & 7 to notify that those patients did not receive all services outlined in the referral to start home health services and will update the medical records according to orders received for the action.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will audit 100% of medical records within 30 days to ensure that 601.31(b), 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. Threshold is 100%. If threshold is not met, the Director of Nursing will contact the physician overseeing the plan of care to notify that those patients did not receive all services outlined in the plan of care. The Director of Nursing will update the medical records according to orders received for the action.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Director of Nursing will educate staff on 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.
The Director of Nursing will review 100% of referrals and to ensure all services outlined in the plan of care can be provided to the patient and will inform the physician ordering if the services cannot be provided. The patient will not be accepted for services and/or the medical record will be updated, as needed with verbal orders.
4. Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all clinical records monthly for 3 months to ensure that 601.31(b) is compliant. Threshold is 100%. If evidence of compliance cannot be obtained then the Director of Nursing or delegated representative will notify the physician and will update the medical records according to orders received for the action. The Director of Nursing will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
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 clinical records (CR), personnel files (PF), agency policy, and an interview with the administrator and alternate director of nursing, the agency failed to provide care according to the physician orders (referral to start home health services) for four (4) of seven (7) clinical records reviewed (CR#2, 4, 6, &; 7).
Findings include:
A review of the agency's policies conducted on January 25, 2023, at approximately 1:00 PM revealed the following:
Policy titled, "5.3 Patient Assessments" stated, "The Individualized plan of care includes the following...All patient care orders, including verbal orders...the types of services, supplies, and equipment required...The home health organization promptly alerts the relevant physician or allowed practitioner(s) to any changes in the patient's condition or needs..."
A review of clinical records was conducted on January 25, 2024, at approximately 9:30 AM and January 31, 2024, at approximately 8:00AM revealed the following:
CR#2. Start of Care: 11/17/23, Certification Period Reviewed: 11/17/23-1/15/24. File contained a "Physician Referral Form" signed by the physician on 11/16/23 that lists orders for: Skilled Nursing and Physical Therapy (three days per week). Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#4. Start of Care: 11/28/23, Certification Period Reviewed: 11/28/23-1/26/24. File contained a "Physician Referral Form" signed by the physician on 11/22/23 that lists orders for: Skilled Nursing and Physical Therapy. Agency does not have a qualified Physical Therapist as an employee or through a contract. File did not contain any physical therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#6. Start of Care: 12/20/23, Certification Period Reviewed: 12/20/23-2/17/24. File contained a "Physician Referral Form" signed by the physician on 12/19/23 that lists orders for: Skilled Nursing, Physical Therapy, and Occupational Therapy. Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
CR#7. Start of Care: 12/5/23, Certification Period Reviewed: 12/5/23-2/2/24. File contained a "Physician Referral Form" signed by the physician on 11/21/23 that lists orders for: Skilled Nursing, Physical Therapy (ambulatory dysfunction), and Occupational Therapy (arthritis in both hands). Agency does not have a qualified Physical Therapist or Occupational Therapist as employees or through a contract. File did not contain any physical therapy or occupational therapy visits conducted. The patient's plan of care did not incorporate the order for physical therapy or occupational therapy. There was no documentation updating the physician about this change in services provided or any verbal orders contained in the file.
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed no evidence of a qualified Physical Therapist. The files did not contain an Occupational Therapist that is contracted or employed by the agency.
An interview conducted with the administrator and alternate director of nursing on January 25, 2024, at approximately 2:00 PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Director of Nursing will contact the physician overseeing the plan of care for CR#2, 4, 6 & 7 to notify that those patients did not receive all services outlined in the referral to start home health services and will update the medical records according to orders received for the action.
5) How the facility will act to protect patients in similar situations
The Director of Nursing will audit 100% of medical records within 30 days to ensure that 601.31(d) is compliant, that 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. Threshold is 100%. If threshold is not met, the Director of Nursing will contact the physician overseeing the plan of care to notify that those patients did not receive all services outlined in the referral to start home health services and did not incorporate orders into the plan of care. The Director of Nursing will update the medical records according to orders received for the action.
6) Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Director of Nursing will educate all staff on requirement 601.31(d), that 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.
The Director of Nursing will review 100% of referrals and to ensure all services outlined in the plan of care can be provided to the patient and will inform the physician ordering if the services cannot be provided. The patient will not be accepted for services and/or the medical record will be updated, as needed with verbal orders.
7) Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all clinical records monthly for 3 months to ensure that requirement 601.31(d) is compliant. Threshold is 100%. If evidence of compliance cannot be obtained then the Director of Nursing or delegated representative will notify the physician and will update the medical records according to orders received for the action. The Director of Nursing will also re-educate staff if non-compliance is found during monthly audits. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
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 a review of agency policy, clinical records (CR) and an interview with the administrator and alternate director of nursing, the agency failed to follow their policy that ensures that the initial assessment visit was held within 48 hours of the referral for three (3) of seven (7) CR's reviewed: CR#1, 4 &; 7.
Findings include:
A review of the agency's policies was conducted on January 25, 2023, at approximately 1:00PM and revealed the following:
Policy titled, "5.3 Patient Assessments/Plan of Care" stated, "An initial assessment visit is completed by a registered nurse, to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment is conducted: within 48 hours of referral or within 48 hours of the patient's return home, or on the physician-ordered start-of-care date..."
A review of clinical records was conducted on January 25, 2023, at approximately 9:30 AM and January 31, 2023, at approximately 8:00AM.
CR#1. Start of Care: 11/1/23. Certification period reviewed: 11/1/23 through 12/30/23. File contained a physician referral form dated 10/23/23. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 11/1/23 which is greater than forty-eight (48) hours after the referral date.
CR#4. Start of Care: 11/28/23. Certification period reviewed: 11/28/23 through 1/26/24. File contained a physician referral form dated 11/22/23. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 11/28/23 which is greater than forty-eight (48) hours after the referral date.
CR#7. Start of Care: 12/5/23. Certification period reviewed: 12/5/23-2/2/24. File contained a physician referral form dated 11/21/23. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 12/5/23 which is greater than forty-eight (48) hours after the referral date.
An interview conducted with the administrator and alternate director of nursing on January 25, 2023, at approximately 2:00PM confirmed the above findings.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The referral log will be monitored daily by the Director of Nursing to ensure compliance with 601.32(b).
2. How the facility will act to protect patients in similar situations
The referral log will be monitored daily by the Director of Nursing to ensure compliance with 601.32(b).
The Director of Nursing will care coordinate with the clinician at the time of referral acceptance and the visit will be scheduled. Then, the Director of Nursing will receive report on the day of the initial assessment from that clinician to ensure timely initiation of care.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Director of Nursing will educate staff on 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 in-service programs, and supervises and teaches other nursing personnel.
The referral log will be monitored daily by the Director of Nursing to ensure compliance with 601.32(b).
The Director of Nursing will care coordinate with the clinician at the time of referral acceptance and the visit will be scheduled. Then, the Director of Nursing will receive report on the day of the initial assessment from that clinician to ensure timely initiation of care.
4. Plans to monitor performance to make sure that solutions are sustained
The Director of Nursing will audit 100% of all medical records monthly for 3 months to ensure that 601.32(b) is compliant. Threshold is 98%. If evidence of compliance cannot be obtained then the Director of Nursing will re-educate staff. Once threshold is met for 3 months in a row, may continue with auditing 10% of medical records quarterly.
The Director of Nursing will monitor the audits and education findings and will report results to the QAPI quarterly and as needed. The QAPI committee will identify if trends exist and what action is recommended to achieve and maintain 100% compliance. The minutes of committee meetings will be presented to the Governing Board for discussion, approval, and action if appropriate.
601.33(a) REQUIREMENT
QUALIFIED THERAPISTS
Name - Component - 00
601.33(a) Qualified Therapists. Any
therapy services offered by the agency
directly or under arrangement are
given by or under the supervision of a
qualified therapist in accordance with
the plan of treatment. The qualified
therapist:
(i) assists the physician in
evaluating level of function,
(ii) helps develop the plan of
treatment (revising as necessary),
(iii) prepares clinical and progress
notes,
(iv) advises and consults with the
family and other agency personnel, and
(v) participates in inservice
programs
Observations:
Based on a review of personnel files (PF), policy and procedures, and an interview with the agency's administrator and alternate director of nursing, it was determined the agency failed to ensure a qualified physical therapist was either an employee or under arrangement for the agency for one (1) of six (6) personnel files reviewed. PF #3
Findings include:
Review of the agency's policy occurred on 1/25/24 at approximately 12:00 PM and revealed the following:
Job Description for "Registered Physical Therapist" stated, "Qualifications: successful completion of a Physical Therapy education program...Must be licensed, or registered by the State of Pennsylvania..."
Policy titled "PA Specific: Therapy Services" stated, "Physical Therapy...the organization shall provide Physical Therapy services, by qualified licensed Physical Therapists..."
A review of personnel files (PF) was conducted on 1/25/24 at approximately 9:30AM and 1/31/24 at approximately 8:00 AM and revealed the following:
PF#3. Date of Hire: 11/15/23. File revealed "Physical Therapist" signed job description. File did not contain any license as a physical therapist. Surveyor reviewed the PA State Licensing Website on 1/25/24 at approximately 11:00 which contained an active "Chiropractor" and "Chiropractor: Adjunctive Procedures" license but did not contain an active Physical Therapist License.
An interview with the agency's administrator on 1/25/24 at approximately 12:30PM confirmed the above findings. The Administrator confirmed Physical Therapy was an offered service, but PF#3 has not seen any patients.
Plan of Correction:1. Elements detailing how the facility will correct the deficiency as it relates to the individual
The Administrator will terminate employment with the employee that belongs to PF#3 due to not meeting licensing requirements as a Physical Therapist.
2. How the facility will act to protect patients in similar situations
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
3. Measures the facility will take or the systems it will alter to ensure that the problem does not recur
The Administrator will educate HR staff on standard 601.33(a) The Administrator will educate HR staff on 601.33(a) Qualified Therapists: any therapy services offered by the agency directly or under arrangement are given by or under the supervision of a qualified therapist in accordance with the plan of treatment. The qualified therapist: (i) assists the physician in evaluating level off unction, (ii) helps develop the plan of treatment (revising as necessary), (iii) prepares clinical and progress notes, (iv) advises and consults with the family and other agency personnel, and (v)participates in in-service programs
Staff will verbalize understanding.
The Director of Nursing will review 100% of new referrals and will not accept referrals that require services that the agency cannot provide until qualified clinicians are hired and ready to accept assignments.
4. Plans to monitor performance to make sure that solutions are sustained
The Administrator will audit 100% of all personnel files monthly for 3 months to ensure that 601.33(a) services provided is met. Threshold is 100%. Once threshold is met for 3 months in a row, may continue with auditing 100% of personnel files annually and within 30 days of hire.
The Administrator will monitor the audits and education findings and will report results to the Governing Board to identify if trends exist and what action is recommended to achieve and maintain 100% compliance.
Initial Comments:Based on the findings of an onsite unannounced state re-licensure survey conducted on January 24, 2024, January 25, 2024, and concluded offsite on January 31, 2024, Edna's 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 unannounced state re-licensure survey conducted on January 24, 2024, January 25, 2024, and concluded offsite on January 31, 2024, Edna's 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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