There are  2 surveys for this facility. Please select a date to view the survey results.

PLAN OF CORRENTION: # 1000: TB SCREENING & PATCH

ACTION OWNER DATE OF COMPLETEION
The agency has in-service the appropriate staff about the requirements of the HR Staff 02/03/2024
initial TB screening and annual verification.

The agency will in-service all active and newly hired staff about the requirements HR STAFF 04/10/2024
of initial TB screening and annual verifications.

The Administrator has instructed all professional staff regarding the requirements
of initial TB screening and annual verifications.

The appropriate staff will complete the second step PPD or obtain negative chest
X-ray if the skin test is positive.

The agency will conduct annual TB Education DON 04/10/2024



PATCH
Advanced HHS LLC has registered with PATCH (Pennsylvania State Police Criminal Background Check). Administrator 01/17/2024

The agency completed PA criminal background check all audited charts during survey. Administrator

The administrator would review all current active employee charts and would obtain criminal 02/15/2024
background checks for all active employees that do not have PA criminal background checks.

The agency would in service of all current employees and upon hiring about state, local HR Staff 04/10/2024
and federal requirements to complete criminal background checks of all current employees.

In-Service will include.
Employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior
to application for employment, the employee will need to obtain a clearance from the
Pennsylvania State Police.
When the employee has not been a resident of the Commonwealth of Pennsylvania for the entire two
years (without interruption) immediately preceding the date of application for employment or
currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check,
the applicant/employee will also need to obtain an FBI Criminal background check.
If the agency runs into special circumstances where they need to hire an employee before the
results of their record checks are returned, the agency will hire staff according to the
provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days
for in state residents and 90 for out of state residents



PROCESS FOR PREVENTING REOCCURENCE


The Administrator will Audit 100 % of all active and newly hired personnel records within 30 days for evidence that an initial baseline TB screening using TST or TB gold was completed.
If any staff tested positive for TB skin test, the staff would be required to complete symptoms evaluation and produce a negative chest X-ray to rule out TB disease.
The agency would conduct TB education within the next 60 days and annually after that would include information on TB risk factors, the signs and symptoms of TB disease, and TB infections control policies and procedures.

These requirements will be discussed at monthly staff meetings for the next sixty days and thereafter quarterly on an ongoing basis.
100% compliance is required and once achieved, compliance will continue to be monitored at quarterly QAPI meetings. Any omission or error in any review will result in the re-education of the staff responsible auditing staff chart.

The administrator would educate and train HR personnel on how to obtain a criminal background check of all employees upon hiring.

Within the next 30 days, HR will conduct PA criminal background checks on all active employees.

PLAN OF CORRENTION: # 1018: PLAN OF TREATMENT &FREQUENCY OF VISITS

ACTION OWNER DATE OF COMPLETION
Advanced HHS LLC would audit 100% of all charts to ensure that frequency of visits DON 03/10/2024

for all skilled and non-skilled patients is included in the Plan of care.

The DON has instructed all professional staff regarding the requirements that DON 03/10/2024
all patients plan of care must contain frequency of visit. Whenever there is change
in doctor's order or the insurance authorizations, such changes must be reflected in
the plan of care and every 60 days/ recertifications.

All staff must demonstrate understanding. 04/10/2024


PTROCESS TO PREVENT REOCCURENCE

For the next thirty days, the DON will audit all charts of active patients, and on admission to ensure that, the frequency of visits is included in the plan of care.

The DON will ensure that all plan of care is updated as needed and least every 60 days to make sure all plan of care contains the frequency of visits. These requirements will be discussed at monthly staff meetings for the next sixty days and thereafter quarterly on an ongoing basis.
100% compliance is required and once achieved, compliance will continue to be monitored at quarterly QAPI meetings. Any omission or error in
any review will result in the re-education of the staff responsible for creating the plan of treatment.

These requirements will be discussed at monthly staff meetings for the next sixty days and thereafter quarterly on an ongoing basis.
100% compliance is required and once achieved, compliance will continue to be monitored at quarterly QAPI meetings. Any omission or error in any review will result in the re-education of the staff responsible for auditing the charts.

PLAN OF CORRENTION: # 1020: PHYSICIAN ORDERS & BLOOD GLUCOSE MONITORING


ACTION OWNER DATE OF COMPLETION
Advanced HHS LLC will audit 100% of all plans of care to ensure Alternate DON 03/10/2024
the plan of care and physician orders are signed within 30 days.

The DON has instructed the assigned staff regarding the requirements Alternate DON 03/10/2024
that all patients' plan of care must be signed within 30 days whenever
there is change in doctor's orders and change in the patients'
treatments or care.

Advanced HHS LLC have hired staff assigned with the responsibility Alternate DON 04/10/2024
of making sure that physician orders are signed by the physician and
returned to the agency within 30 days.


The agency has in-service the appropriate staff about the monitoring
and administration of insulin per doctor's order related to carbohydrates Alternate DON
count and monitoring of Ketones in urine.
The staff demonstrated understanding.

The Alternate DON will instruct all professional staff regarding the Alternate DON 04/10/2024
documentation and administration of insulin.


PROCESS TO PREVENT REOCCURENCE

The assigned staff would follow up with the physician's office on a regular basis with phone calls, fax and email to ensure the orders are signed in a timely manner.
Advanced HHS LLC would keep track of all efforts made to obtain signed physician orders.

For the next thirty days, the Alternate DON will audit all charts of active patients, and on admission to ensure that, the plan of care and physician orders are signed within 30 days whenever there is change in doctor's orders and change in the patient's treatment or care.

The Alternate DON will ensure that all plan of care is updated as needed and at least every 60 days and such updates in the plan of care must be signed by the designated physician within 30 days.

These requirements will be discussed at monthly staff meetings for the next sixty days and thereafter quarterly on an ongoing basis.

100% compliance is required and once achieved, compliance will continue to be monitored at quarterly QAPI meetings. Any omission or error in any review will result in the re-education of the designated staff responsible for the plan of treatment.

These requirements will be discussed at monthly staff meetings for the next sixty days and thereafter quarterly on an ongoing basis.

100% compliance is required and once achieved, compliance will continue to be monitored at quarterly QAPI meetings. Any omission or error in any review will result in the re-education of the staff responsible for signing of plan of care and physician orders.

For the next 30 days, the Alternate DON will audit the nurse's documentation whenever a patient returns from California to ensure that the nurse is documenting and addressing blood glucose per doctor's order.

The Alternate DON will audit the documentation of all active patients with diabetes and on admission to ensure proper documentation.

The Alternate DON will provide service / training for all active patient with diabetes and on admission about administration and documentation of insulin according to doctor's orders.

The Alternate DON will in service / train staff how to address blood glucose according to the doctor's order related to carbohydrates counts and monitoring ketones in urine upon admission.

The Alternate DON will ensure that any changes in physician orders are properly reflected in nurse's documentation as needed and least every 60 days. These requirements will be discussed at monthly staff meetings for the next sixty days and thereafter quarterly on an ongoing basis. 100% compliance is required and once achieved, compliance will continue to be monitored at quarterly QAPI meetings. Any omission or error in any review will result in the re-education of the staff responsible.