Initial Comments:
Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted on June 5, 2023 and June 6, 2023, Eldacare Home Health Services Inc. was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G, Chapter 601.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on a review of personnel files (PF), home health agency (HHA) policies, HHA position descriptions, and an interview with the administrator, the agency failed to assure that a social worker met the qualifications as outlined in the agency's position description for one (1) of seven (7) personnel files reviewed: PF#4.
Findings include:
On June 6, 2023 starting at approximately 11:00 AM, a review of the following agency policies took place:
Policy 4.2 Required Information reads in part, "Personnel credentials: Documentation of compliance with the training requirements for each position, including applicable state licensure, is maintained in each person's file in the agency office;" and "Verification of qualifications for the duties assigned, including on-line licensure verification for professional employees, current licensure, registration, diploma copy, degree or transcript, and certificate of training for all care workers;" and "signed job descriptions for every role staff will be performing."
Policy 4.6 Job Descriptions states in part, "Personnel File Components - Minimum job qualifications;" and "Review of the job description with personnel is conducted as part of the orientation process and whenever the job description changes."
On June 6, 2023 starting at approximately 11:15 AM, a review of the agency's manual titled, "Staff Orientation Program & Performance Evaluations Binder" contained a Master List of all HHA positions and their associated position descriptions. The position description contained in the manual titled Medical Social Worker included the following qualifications in part, "Must have a license in the state of Pennsylvania," and "Must have a current cardiopulmonary (CPR) certification."
On June 6, 2023 at approximately 2:30 PM, a review of the website Board of Behavioral Sciences (bbs.ca.gov) was conducted. The Board of Behavioral Sciences (BBS) is a California state regulatory agency responsible for licensing, examination and enforcement of professional standards for licensed clinical social workers in the state of California.
A review of personnel files was conducted on June 6, 2023 starting at 10:00 AM. The date of hire (DOH) is indicated below.
PF#4 DOH 05/23/2023 contained a Medical Social Worker job description that included the following qualifications in part, "Must be licensed by the Board of Behavioral Science," and "Must have current CPR certification." The position description was signed on 05/23/2023 by the employee. The file did not contain any type of social worker licensure from any state agency, nor was there any evidence of CPR certification.
An interview was conducted with the administrator on June 6 2023 starting at 11:45 AM. The administrator stated that it is not the HHA's policy to require licensure or CPR certification for the social worker position, and that the inclusion of such qualifications in the signed position description and the master position description for a Medical Social Worker was an oversight.
An interview conducted with the administrator and the alternate administrator on June 6, 2023 starting at 12:00 PM confirmed the above findings.
Plan of Correction:Standard deficiency: 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
Responsible party who will correct and prevent deficiency: Governing body and Director of Nursing
Plan of correction/process to prevent recurrence:
The governing body has met on 6/12/2023 and approved motion policy/procedures/written processes and other required documentation, accurate to regulation as listed below:
Revise Job description qualifications for Medical Social worker as follows:
- Remove need for active CPR Certification
- Remove need to be licensed by Board of Behavioral Sciences.
Revise Job description qualifications for Medical Social worker Assistant as follows:
- Remove need for active CPR certification
Meeting minutes have been documented.
The governing body will meet as specified in policy 1.5 Meetings are held, at a minimum of, yearly. Special or emergency meetings may be called at any time, and telephone conference meetings may be held. The governing body shall: Adopt and revise, as needed, policies and procedures for the operation and administration of the agency. The agency shall have written administrative policies and procedures to ensure that the patient or client is provided safe and adequate care.
Director of Nursing will Audit 100% of active personnel files to ensure that Personnel records include qualifications, licensure, performance evaluations, health examinations, documentation of orientation provided, and job descriptions, and are kept current
Threshold is 100%. Once threshold is met for 30 days, agency will audit 10% of active Personnel files will be audited. quarterly to ensure that there is compliance.
If there is noncompliance, agency will revert back to 100% audits monthly until 100% compliance is reached.
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), home health agency (HHA) policies, and an interview with the administrator, the agency failed to conduct an initial occupational therapy (OT) evaluation in a timely manner, and failed to obtain physician approval to modify the original plan of care for one (1) of seven (7) CR's reviewed: CR#5.
Findings include:
On June 5, 2023 starting at approximately 2:45 PM, a review of the following agency policies took place:
Policy 5.4 Initial Assessment Requirements reads in part, "All new admissions will be reviewed, in a timely manner, by the professional staff and appropriate supervisor, to ensure that staff is appropriately assigned."
Policy 5.22 Verbal Orders states in part, "The HHA's personnel promptly alert the physician(s) to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered;" and "Conformance with physician's orders: Prescriptions and nonprescription drugs, devices, medications, and treatments are administered by agency staff in accordance with the written orders of the physician."
Policy 5.23 Physician Notification To Alter The Plan of Care reads in part, "The HHA's personnel promptly alert the physician(s) to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. The patient record must demonstrate evidence that the physician was promptly informed of any changes that suggest a need to alter the plan of care."
A review of CR was conducted on June 5, 2023 starting at approximately 11:15 AM. The start of care (SOC) and Certification Period (CP) for the Home Health Certification and Plan of Care (CMS-485) are indicated below.
CR#5 SOC 08/10/2022 and CP 08/10/2022 to 10/08/2022 contained orders on the CMS-485 for Occupational Therapy (OT) one (1) visit per week for six (6) weeks starting 08/10/2022 and ending 09/17/2022. A review of the visit calendars from 08/10/2022 to 09/15/2022 (discharge date) found that the initial OT evaluation was not attempted until 08/22/2022, 12 days after the ordered SOC, at which time the OT documented a missed visit due to no answer to phone call. There were no other OT visits recorded in the clinical record nor in the visit calendars. A skilled nursing (SN) visit note on 08/18/2023 documented that the patient was "reluctant to do OT." A SN visit note on 08/25/2023 documented that OT would be cancelled due to patient preference. The discharge summary documented by SN on 09/12/2023 noted that OT services were not provided due to patient preference. There was no evidence of a physician order to discontinue OT services, evidence of an updated plan of care, nor evidence that the physician was notified at any time of the discontinued OT services.
An interview was conducted on June 6, 2023 at approximately 9:45 AM with the registered nurse (RN) who provided care to CR#5. The RN confirmed that the first OT visit was not attempted until 08/22/2022. The RN stated that the patient's desire to not receive OT services was communicated to the physician via phone, but the RN confirmed that there was no documentation that the physician was notified of a change to the plan of care, nor that a physician order was obtained to discontinue OT services.
An interview conducted with the administrator and alternate administrator on June 6, 2023 starting at approximately 12:00 PM confirmed the above findings.
Plan of Correction:Standard deficiency: 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.
Responsible party who will correct and prevent deficiency: Director of Nursing
Director of Nursing will re-instruct the HHA personnel with in-service related to Policy 5.4, Policy 5.22 and Policy 5.23 to ensure that , the agency conducts all initial evaluations in a timely manner, and physical approval is obtained to modify the original plan of care.
Policy 5.4 Initial Assessment Requirements which reads in part, "All new admissions will be reviewed, in a timely manner, by the professional staff and appropriate supervisor, to ensure that staff is appropriately assigned."
Policy 5.22 Verbal Orders states in part, "The HHA's personnel promptly alert the physician(s) to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered;" and "Conformance with physician's orders: Prescriptions and nonprescription drugs, devices, medications, and treatments are administered by agency staff in accordance with the written orders of the physician."
Policy 5.23 Physician Notification To Alter The Plan of Care reads in part, "The HHA's personnel promptly alert the physician(s) to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. The patient record must demonstrate evidence that the physician was promptly informed of any changes that suggest a need to alter the plan of care."
Staff will verbalize understanding of instruction.
Process to prevent recurrence:
Director of Nursing will Audit 100% of all active patients charts monthly to ensure that the Policies 5.4, 5.22, and 5.23 are being properly followed and the agency conducts all initial evaluations in a timely manner, and physical approval is obtained to modify the original plan of care.
Policy 5.4 Initial Assessment Requirements which reads in part, "All new admissions will be reviewed, in a timely manner, by the professional staff and appropriate supervisor, to ensure that staff is appropriately assigned."
Policy 5.22 Verbal Orders states in part, "The HHA's personnel promptly alert the physician(s) to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered;" and "Conformance with physician's orders: Prescriptions and nonprescription drugs, devices, medications, and treatments are administered by agency staff in accordance with the written orders of the physician."
Policy 5.23 Physician Notification To Alter The Plan of Care reads in part, "The HHA's personnel promptly alert the physician(s) to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. The patient record must demonstrate evidence that the physician was promptly informed of any changes that suggest a need to alter the plan of care."
Target threshold is 100%. Once threshold is met, will continue to audit 10% of all patient records quarterly to ensure that there is compliance. If there is noncompliance, agency will revert back to 100% audits monthly until 100% compliance is reached. Director of Nursing will report all results to the QAPI committee.
Initial Comments:
Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted on June 5, 2023 and June 6, 2023, Eldacare Home Health Services Inc. was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted on June 5, 2023 and June 6, 2023, Eldacare Home Health Services Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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