Initial Comments:
Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted August 3, 2023 and offsite on August 4, 2023 and August 7, 2023, Abundant 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(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 agency policies, governing body meeting minutes, and an interview with the administrator, the agency failed to provide documentation that the governing body review and approve the annual program evaluation, the annual budget, and agency policies and procedures.
Findings include:
A review of agency policy titled, "Governance Policy" was conducted on August 8, 2023 at approximately 11:00 am. Policy states, "Duties of the Board of Directors include the following: 3. Hold management accountable for fiscal solvency of the organization and adequacy of financial resources, including approval of budgets and capital expenditures...11. Adopt, approve, and at least review annually and as necessary, new or revised Agency By-laws, mission statement, personnel policies, and patient/client care policies and procedures consistent with organizational philosophy and mission/purpose. 12. Develop and approve the Strategic Plan..."
A review of the Governing Body meeting minutes was conducted on August 3, 2023 at approximately 12:00 pm. Meetings were held on 10/3/2022, 1/5/2023, 4/5/2023, and 7/10/2023. There was no documentation in any of the meeting minutes that the governing body reviewed and approved the annual budget, the agency by-laws, mission statement, agency policies and procedures, or the annual program evaluation.
An interview with the administrator conducted on August 3, 2023, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
As of 8/9/2023 Abundant Care has supplemented its administrative staff to
include an office
manager. Duties pertinent to this finding will include completing accurate meeting minutes and providing them to the Administrator within one business day for review to ensure that all reviews and approvals are addressed during monthly and quarterly meetings. The Administrator will be responsible for maintaining completed meeting minute records onsite for no less than 5 years. (please see attached job description: "Office Manager")
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on review of agency policy, personnel files (PF), Centers for Disease Control Tuberculosis Testing Guidelines, and an interview with administrator, the agency failed to provide documentation of signed job descriptions for six (6) of six (6) PF's reviewed, (PF #1, 2, 3, 4, 5, and 6); failed to provide documentation of a current state issued nursing license for one (1) of six (6) PF's reviewed, (PF# 6); failed to provide documentation of an initial competency evaluation for two (2) of six (6) PF's reviewed, (PF #2 and 6); failed to provide documentation of a Pennsylvania State (PATCH) Background check for two (2) of six (6) PF's reviewed, (PF# 2 and 3); failed to provide FBI Background Clearance documentation for one (1) of six (6) PF's reviewed, (PF #5); failed to provide documentation of Child Abuse Clearance for four (4) of six (6) PF's reviewed, (PF# 1, 3, 4, 5, and 6); failed to provide orientation documentation for six (6) of six (6) PF's reviewed, (PF #1, 2, 3, 4, 5, and 6); failed to provide Hepatitis B vaccination/declination documentation for three (3) of six (6) PF's reviewed, (PF #1, 2, 5, and 6); and failed to provide documentation of tuberculosis testing, and/or symptom screening, and risk assessment at hire for five (5) of six (6) PF's reviewed, (PF# 1, 2, 4, 5, and 6)
Findings Included:
A review of agency policy titled "Contents of Personnel Record" was conducted on August 8, 2023 at approximately 11:30 am states, "All documentation provided by the employee must have current dates. f. For professional employees a license copy. j. a signed and dated job description form. Employee's health record shall include: Per CDC Guidelines, a two step Mantoux PPD or approved blood test upon hire. Evidence of acceptance or declination of Hepatitis B vaccine..."
A review of agency policy titled, "Abundant Care Background Check Policy" was conducted on August 8, 2023 at approximately 11:40 am states, "Abundant Care LLC will perform 3 Mandatory background checks for all staff: Criminal Background PATCH: a State Background Check for prospective employee. Individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record. FBI FINGERPRINT: If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the the request for a criminal history report, the individual shall obtain a Federal criminal history record and a letter of determination from the Department of Aging, based on the individual's Federal criminal history record. Child Abuse Clearance for prospective employee. A Child abuse clearance check is required for anyone providing care for child under 21 years old...."
A review of agency policy titled, "Abundant Care Orientation Policy for Home Health Agency" was conducted on August 8, 2023 at approximately 11:45 am. Policy states, "Purpose: Abundant Care provides all new employees with the information and resources they need to integrate effectively into the agency and perform their roles competently... Documentation: Attendance sheets, evaluations, or quizzes to ensure understanding in addition to training on our documentation system..."
A review of agency policy titled, "Competencies" was conducted on August 8, 2023 at approximately 11:50 am. Policy states, "Initial Competency Assessment: New employees shall undergo an initial competency assessment upon hire to determine their baseline knowledge and skills. The assessment will be tailored to each employee's role and responsibilities and will include both clinical and non-clinical components..."
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray 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, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
A review of PF's conducted on August 3, 2023 from approximately 10:00 am to 10:40 am revealed the following:
PF #1, Date of Hire: 8/10/2020, did not contain any documentation of: a signed job description for administrator, alternate director of nursing, or registered nurse; Child Abuse Clearance; orientation documentation, initial competency; Hepatitis B vaccine/declination; and tuberculosis testing, symptom screening, or risk assessment at hire.
PF#2, Date of Hire: 8/10/2020, did not contain any documentation of: a signed job description for director of nursing, alternate administrator, or registered nurse; a PATCH; orientation documentation; initial competency evaluation; Hepatitis B vaccine/declination; and a tuberculosis symptom screening, or risk assessment at hire.
PF #3, Date of Hire: 6/2/2023, did not contain any documentation of: a signed job description; a PATCH; and orientation documentation.
PF #4, Date of Hire: 7/10/2023, did not contain any documentation of: a signed job description; a Child Abuse Clearance; orientation documentation; and tuberculosis testing, symptom screening, or risk assessment at hire.
PF#5, Date of Hire: 7/6/2023, did not contain any documentation of: a signed job description; an FBI Background Check (has Delaware license issued 9/25/2020 and application states a Delaware address); a Child Abuse Clearance; orientation documentation; Hepatitis B vaccine/declination; and a tuberculosis symptom screening, or risk assessment at hire.
PF#6, Date of Hire: 6/5/2023, did not contain any documentation of: a signed job description; a Child Abuse Clearance; a current copy of PA LPN license; orientation documentation; initial competency; and a tuberculosis symptom screening, or risk assessment at hire.
An interview with the administrator on August 3, 2023, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
As of 8/10/2023 audit of all personnel records was completed. All
aforementioned missing
documentation has been
updated to meet the
requirements of
regulation 601.21 (f). In
an effort to maintain
compliance As of 8/9/2023
Abundant Care has
supplemented its
administrative staff to
include an office
manager. Duties pertinent to this finding will include completing a comprehensive audit of all new hire personnel files prior to the employees official start date. In addition, the office manager and/or their designated delegatee/delegatees will complete quarterly audits to all personnel files. The office manager will be responsible for maintaining a running database that includes upcoming expiration dates for all time limited documents (please see attached job description: "Office Manager"). The Administrator will monitor and oversee the these duties assigned to the Office Manager to ensure compliance. In addition, the duties of the Director of Nursing (DON) have been updated to include the following responsibilities/titles; "Infection Control Nurse", "Nurse Educator". The duties of the Infection Control Nurse pertinent to regulation 601.21 (f) include tracking and maintaining personnel compliance with Tuberculosis testing/symptom tracking and Hep B vaccination records and/or acceptance/declination. The duties of the Nurse Educator pertinent to regulation 601.21 (f) include conducting, tracking of completion, and maintenance of documentation pertaining to Orientation and completion of all skills Competencies.
601.22(a) REQUIREMENT
ANNUAL POLICY REVIEW
Name - Component - 00
601.22(a) Annual Policy Review. A
group of professional personnel, which
includes at least one practicing
physician and one registered nurse,
and with appropriate representation
from other professional disciplines,
establishes and annually reviews the
agency's policies governing scope of
services offered, admission and
discharge policies, medical
supervision and plans of treatment,
emergency scope of services offered,
medical care, clinical records,
personnel qualifications, and program
evaluation.
Observations:
Based upon review of Professional Advisory Committee (PAC) meeting minutes, policy and procedure review, and interview with the administrator, it was determined the agency failed to ensure the Professional Advisory Committee (PAC) established and reviewed the agency's policies and procedures on an annual basis for 2022 or 2023.
Findings include:
A review of agency policy "Professional Advisory Committee" was conducted on August 8, 2023 at approximately 12:00 pm. Policy states, "Objective of the Professional Advisory Committee (PAC) Meeting: Abundant care evaluation of the agency ' s total program at least once a year by the group of professional personnel or a committee of this group, home health care agency staff and consumers; or by professional people outside the agency working in conjunction with consumers. The evaluation shall consist of an overall policy and administrative review and a clinical record review..."
There was no documentation of any Professional Advisory Committee (PAC) meetings for 2022 or 2023.
An interview with the administrator conducted on August 3, 2023 at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
A PAC review has been (conducted on/scheduled to be conducted on)
8/10/23 in an
effort to maintain compliance with regulation 601.22 (a) Annual Policy Review, Abundant Care has supplemented its administrative staff to include an office manager. Duties pertinent to this finding will include
tracking and scheduling all necessary Administrative meetings and reviews including but not limited to the PAC review. In addition, the Office Manager will be responsible for providing accurate documentation for said meetings/reviews by way of meeting minutes to the Administrator for review and approval within one business day of meeting/review. The Administrator will be responsible for maintaining the completed record of reviews on-site for no less than 5 years
601.22(b) REQUIREMENT
ADVISORY AND EVALUATION FUNCTION
Name - Component - 00
601.22(b) Advisory and Evaluation
Function. The group of professional
personnel meets at least annually to
advise the agency on professional
issues, participate in the evaluation
of the agency's program and assist the
agency in maintaining liason with
other health care providers in the
community information program. Its
meetings are documented by dated
minutes. Note dates of last two
meetings.
Observations:
Based on an interview with the agency administrator, review of agency policy, and review of professional advisory group meeting minutes, the agency failed to ensure there was documentation to show the professional advisory committee met annually to advise the agency on professional issues.
Findings include:
A review of agency policy "Professional Advisory Committee" was conducted on August 8, 2023 at approximately 12:00 pm. Policy states, "Objective of the Professional Advisory Committee (PAC) Meeting: Abundant care evaluation of the agency s total program at least once a year by the group of professional personnel or a committee of this group, home health care agency staff and consumers; or by professional people outside the agency working in conjunction with consumers. The evaluation shall consist of an overall policy and administrative review and a clinical record review..."
Agency did not provide any documentation of PAC meeting minutes for 2022 or 2023.
Interview with the administrator on August 3, 2023, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
A PAC review has been (conducted on/scheduled to be conducted on)
8/7/23
effort to maintain compliance with regulation 601.22 (a) Annual Policy Review, Abundant Care has supplemented its administrative staff to include an office manager. Duties pertinent to this finding will include tracking and scheduling all necessary administrative meetings and reviews including but not limited to the PAC review. In addition, the Office
Manager will be responsible for providing accurate documentation for said meetings/reviews by way of meeting minutes and meeting sign in sheet to the Administrator for review and approval within one business day of meeting/review. The Administrator will be responsible for maintaining the completed record of reviews on site for no less than 5 years.
601.22(c) REQUIREMENT
ANNUAL PROGRAM EVALUATION
Name - Component - 00
601.22(c) Annual Program Evaluation.
The home health agency has written
policies requiring an overall
evaluation of the agency's total
program at least once a year by: (i)
the group of professional personnel
(or a committee of this group), agency
staff and consumers, or by (ii)
professional people outside the agency
working in conjunction with consumers.
The evaluation consists of an overall
policy and administrative review and a
clinical record review. The
evaluation assesses the extent to
which the agency's program is
appropriate, adequate, effective and
efficient. Results of the evaluation
are reported to and acted upon by
those responsible for the operation of
the agency and are maintained
separately as administrative records.
As a part of the evaluation process
the policies and administrative
practices of the agency are reviewed
to determine the extent to which they
promote patient care that is
appropriate, adequate, effective, and
efficient. Mechanisms are established
in writing for the collection of
pertinent data to assist in
evaluation. The data to be considered
may include but are not limited to:
number of patients receiving each
service offered, number of patient
visits, reasons for discharge,
breakdown by diagnosis, sources of
referral, number of patients not
accepted, with reasons, and total
staff days for each service offered.
Observations:
Based on a review of agency policy, agency documentation, and interview with the administrator, it was determined that the agency failed to conduct a annual program evaluation for 2022.
Findings include:
A review of the agency policy titled "Annual Program Evaluation", conducted on August 3, 2023, at approximately 11:00 am states, "Policy: The agency, through the governing body, advisory committee and agency staff, shall annually evaluate, the extent to which the agency's program is appropriate, adequate, effective, and efficient..."
Review of documentation on August 3, 2023 at approximately 1:30 pm revealed:
There was no documentation of any Professional Advisory Committee (PAC) meetings for 2022 or 2023.
Governing Body meetings were held on 10/3/2022, 1/5/2023, 4/5/2023, and 7/10/2023. Governing Body Meeting minutes did not contain any documentation of an annual program evaluation that consists of an overall policy and administrative review.
An interview with the administrator on August 3, 2023 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Plan of Correction:
A PAC review has been (conducted on/scheduled to be conducted on)
8/7/23
effort to maintain compliance with regulation 601.22 (a) Annual Policy Review, Abundant Care has supplemented its administrative staff to include an office manager. Duties pertinent to this finding will include tracking and scheduling all necessary Administrative meetings and reviews including but not limited to the PAC review. In addition, the Office Manager will be responsible for providing accurate documentation for said meetings/reviews by way of meeting minutes and meeting sign in sheets to the Administrator for review and approval within one business day of meeting/review. The Administrator will be responsible for maintaining the completed record of reviews on site for no less than 5 years.
601.31(b) REQUIREMENT
PLAN OF TREATMENT
Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).
If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.
Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.
Observations:
Based on a review of agency policy, clinical record (CR) reviews, and an interview with the administrator, the agency failed to follow its policy regarding items to be included in the plan of care for five (5) of five (5) CR's reviewed. (CR #1, 2, 3, 4, and 5).
Findings include:
A review of policy titled "Care Plan Policy" completed on August 8, 2023 at approximately 12:15 pm states, "To ensure that a patient's needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential. A care plan is started upon initiation of service by the RN, based upon the plan of treatment and an assessment of the patient's needs, resources, family and environment...The patient care plan shall be updated as often as the patient's condition indicates but at least every sixty (60) days. The plan shall be maintained as a permanent part of the patient's record...Steps to be taken in developing the care plan include: 1.Collection of baseline data including all pertinent diagnoses, including mental status, types of services, identification of any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, instructions for timely discharge or referral and any other appropriate items..."
A review of CR's was conducted on August 3, 2023 from approximately 11:00 am to 1:00 pm revealed the following:
CR #1, Start of Care: 6/11/2023, Home Health Certification and Plan of Care period reviewed 6/11/2023 through 8/9/2023 contained only interventions for SN (Skilled Nursing). There was no documentation of SN order, frequency, or duration of visits.
CR #2, Start of Care: 5/26/2023. Home Health Certification and Plan of Care period reviewed 7/25/2023 through 9/22/2023 contained only interventions for SN. There was no documentation of SN order, frequency, or duration of visits.
CR #3, Start of Care: 5/25/2023. Home Health Certification and Plan of Care period reviewed 7/24/2023 through 9/21/2023 did not contain any documentation of orders, frequency, or duration for SN visits and contained orders for Home Health Aide (HHA) for forty-five (45) hours weekly. There is no duration documented for the HHA visits.
CR #4, Start of Care: 3/9/2023. Discharge Date: 4/15/2023. Home Health Certification and Plan of Care period reviewed 3/9/2023 through 5/7/2023
contained only interventions for PT (Physical Therapy) and OT (Occupational Therapy). There was no documentation of PT or OT order, frequency, or duration of visits.
CR#5, Start of Care: 3/2/2023. Discharge Date: 4/17/2023. Home Health Certification and Plan of Care period reviewed 3/2/2023 through 4/30/2023 states, "Patient discharged from nursing home with orders for PT (eval and treatment), OT (eval and treatment), and SN." There is no frequency or duration of SN visits documented.
An interview with the administrator on August 3, 2023 at approximately 2:00 pm confirmed the above findings.
Plan of Correction:As of 8/9/2023 the aforementioned POC's have been updated to be in compliance with
regulation 601.31 (b). In
an effort to maintain
compliance the following
measures/procedures have
been put in place. All
completed plan of cares
must be submitted to,
reviewed for accuracy and
compliance and approved
by the DON within 24
hours of completion. In
the event the initial POC
was completed by the
Director of Nursing this
POC must be submitted to,
and reviewed for accuracy
and compliance by any
other Administrative RN
prior to resubmittal to
DON for approval. Any
updates made to the care
plan must be submitted to,
reviewed for accuracy and
compliance and approved
by the DON within 24
hours of update. In the
event the initial POC
update was made by the
Director of Nursing this
POC must be submitted to,
and reviewed for accuracy
and compliance by any
other Administrative RN
prior to resubmittal to
DON for approval. In
addition, a POC audit will
be conducted by an
Administrative RN as
assigned every 60 days in
each plan of care in an
effort to ensure accuracy.
601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS
Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.
Observations:
Based on a review of agency policy, clinical record (CR) reviews, and interview with the administrator, the agency failed to provide care in accordance with the plan of care for two (2) of five (5) CR's reviewed (CR #4 and 5).
Findings include:
A review of agency policy titled "Care Plan Policy" was conducted on August 8, 2023 at approximately 12:15 pm. Policy states, "To ensure that a patient's needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential. A care plan is started upon initiation of service by the RN, based upon the plan of treatment and an assessment of the patient's needs, resources, family and environment...The patient care plan shall be updated as often as the patient's condition indicates but at least every sixty (60) days. The plan shall be maintained as a permanent part of the patient's record...Steps to be taken in developing the care plan include: 1. Collection of baseline data including all pertinent diagnoses, including mental status, types of services, identification of any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, instructions for timely discharge or referral and any other appropriate items...11. Establishment of a schedule for the provision of services which lists the description and frequency of each health care service, the required treatment and procedure, as well as the medication and diet regimen to be provided..."
A review of CR's was conducted on August 3, 2023 from approximately 11:00 am to 1:00 pm revealed the following:
CR #4, Start of Care: 3/9/2023. Discharge Date: 4/15/2023. Home Health Certification and Plan of Care Certification period reviewed 3/9/2023 through 5/7/2023, contained interventions for PT (Physical Therapy), but did not contain any frequency or duration for PT visits. Visit documentation revealed no documentation that any PT visits were conducted. File did not contain a PT evaluation or any missed visit documentation for any PT visits and there was no discontinuation order for PT noted.
CR#5, Start of Care: 3/2/2023. Discharge Date: 4/17/2023. Home Health Certification and Plan of Care Certification period reviewed 3/2/2023 through 4/30/2023 states "Patient discharged from nursing home with order for PT (eval and treatment), OT (Occupational Therapy) (eval and treatment), and SN". There is no documentation of frequency or duration for SN.
Visit documentation revealed the following:
PT evaluation was completed on 3/8/2023 and a PT visit was conducted on 3/29/2023. File did not contain a copy of the PT evaluation and agency is unable to supply a copy at this time. This surveyor was unable to determine the frequency or duration of PT visits ordered.
SN start of care assessment was completed on 3/2/2023 and discharge assessment was completed on 4/17/2023. File did not contain a copy of either assessment and agency is unable to supply a copy at this time. No other SN visits were documented.
An interview with the administrator conducted on August 3, 2023 at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
In an effort to maintain compliance with regulation 601.31 (d) As of 8/9/2023
the following
measures/procedures have been put in place. A review of all patient files which includes initial Physician orders will be conducted by the DON and/or their assigned RN delegatee prior to care being rendered. This review will include but not be limited to review of reconciliation of physician orders, and assurance that all personnel needed to provide ordered care to the patient have been assigned and appropriate care is being received and documented. In addition, the DON or theirLicensed Nurse delegatee/delegatees will conduct a review of all physician order reconciliations every 24 hours. This review will include but is not limited to ensuring that all verbal orders have been accurately recorded and signed by a physician within 7 days. In the event the initial reconciliation of physician orders was completed by the Director of Nursing this reconciliation must be submitted to, and reviewed for accuracy and compliance by any other Administrative RN prior to resubmittal to DON for approval.
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 clinical records (CR), agency policies, and an interview with the Administrator, the agency failed to ensure the registered nurse (RN) followed agency policy by completing a timely and/or complete initial and/or comprehensive assessment or reassessment prior to the start of the certification period for one (1) of five (5) CR's reviewed, (CR#3).
Findings include:
A review of agency policy titled "Care Plan Policy" was conducted on August 8, 2023 at approximately 12:15 pm. Policy states, "To ensure that a patient's needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential. A care plan is started upon initiation of service by the RN, based upon the plan of treatment and an assessment of the patient's needs, resources, family and environment...The patient care plan shall be updated as often as the patient's condition indicates but at least every sixty (60) days. The plan shall be maintained as a permanent part of the patient's record...Steps to be taken in developing the care plan include: 1. Collection of baseline data including all pertinent diagnoses, including mental status, types of services, identification of any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, instructions for timely discharge or referral and any other appropriate items..."
A review of CR's was conducted on August 3, 2023 from approximately 11:00 am to 1:00 pm.
CR #3, Start of Care: 5/25/2023. Home Health Certification and Plan of Care period reviewed 7/24/2023 through 9/21/2023 contained orders for Home Health Aide (HHA) forty-five (45) hours weekly. There is no duration for the HHA visits. File did not contain any documentation of an initial RN assessment and no RN re-assessment at the start of certification period reviewed.
An interview with the administrator on August 3, 2023 at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
In an effort to maintain compliance with regulation 601.32(b) As of 8/10/2023 the following measures/procedures have been put in place. The DON or their Administrative RN delegatee/delegatees will conduct a weekly comprehensive review of all patient charts. This review includes but is not limited to ensuring that all assessments/reassessments are completed in a timely fashion, review of reconciliation of physician orders, and assurance that all personnel needed to provide ordered care to the patient have been assigned and that appropriate care is being rendered and documented, and review of all POC's with assurance that all summary reports are sent to, reviewed, signed by physicians and maintained in patient record.
601.36(a) REQUIREMENT
MAINTENANCE AND CONTENT OF RECORD
Name - Component - 00
601.36(a) Maintenance and Content of
Record. A clinical record is
maintained in accordance with accepted
professional standards and contains:
(i) pertinent past and current
findings,
(ii) plan of treatment,
(iii) appropriate identifying
information,
(iv) name of physician,
(v) drug, dietary, treatment and
activity orders,
(vi) signed and dated clinical
progress notes (clinical notes are
written the day service is rendered
and incorporated no less often than
weekly),
(vii) copies of summary reports sent
to the physician, and
(viii) a discharge summary.
Observations:
Based on a review of clinical records (CR), agency policy, and an interview with the administrator, the agency failed to maintain the clinical record in accordance with accepted professional standards for four (4) of five (5) CR's reviewed, (CR #2, 3, 4, and 5).
Findings include:
A review of agency policy titled "Clinical Record Contents" on August 3, 2023, at approximately 1:15 pm states, "The clinical record includes the following information:...copies of summary reports sent to physicians...discharge summary...Discharge Summary: A discharge summary is to be completed on all patients/clients discharged from the Agency. It is to be completed within five days of discharge..."
A review of CR's was conducted on August 3, 2023, from approximately 110:00 am through 1:00 pm.
CR #2; Start of Care: 5/26/2023; Certification period reviewed: 7/25/2023 through 9/22/2023; did not contain any documentation that a 60 day summary had been completed and sent to the physician.
CR #3; Start of Care: 5/25/2023; Certification period reviewed: 7/24/2023 through 9/21/2023; did not contain any documentation that a 60 day summary was completed and sent to the physician.
CR #4; Start of Care: 3/9/2023; Discharge Date: 4/15/2023. Certification period reviewed: 3/9/2021 through 5/7/2023; did not contain any documentation that a discharge summary was completed and sent to the physician.
CR #5; Start of Care: 3/2/2023; Discharge Date: 4/17/2023; Certification period reviewed: 3/2/2023 through 4/30/2023; states "Patient discharged from nursing home with order for PT (eval and treatment), OT (Occupational Therapy) (eval and treatment), and SN". There is no documentation of frequency or duration for SN.
Visit documentation revealed the following:
PT evaluation was completed on 3/8/2023 and a PT visit was conducted on 3/29/2023. File did not contain a copy of the PT evaluation and agency is unable to supply a copy at this time.
SN start of care assessment was completed on 3/2/2023 and discharge assessment was completed on 4/17/2023. File did not contain a copy of either assessment and agency is unable to supply a copy at this time.
File did not contain any documentation that a discharge summary was completed and sent to the physician.
An interview with the administrator on August 3, 2023, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Plan of Correction:
To maintain compliance with regulation 601.36(a) Maintenance and Content of Record.
Abundant Care Plans to Change software to more user friendly software so that 60 day summaries will be included in with plan of cares, Assessments, Discharges, So that PCP's can receive summaries immediately after Disciplines enter them in.
New Software will populate Frequency and duration of care in accordance with MD orders.
Previous software would allow discipline to enter frequency but would not populate in the appropriate box.
Supervisory RN will conduct weekly chart checks to ensure that all appropriate frequencies and visits are made for each client. Added to Supervisory/ Don job description. Chart Checks to be done every Tuesday.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on August 3, 2023 and offsite on August 4, 2023 and August 7, 2023, Abundant Care, LLC., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on August 3, 2023 and offsite on August 4, 2023 and August 7, 2023, Abundant 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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