QA Investigation Results

Pennsylvania Department of Health
BISTOY HOME HEALTHCARE, INC.
Health Inspection Results
BISTOY HOME HEALTHCARE, INC.
Health Inspection Results For:


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

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted on May 13, 2024 through May 14, 2024 and offsite on May 21, 2024 through May 22, 2024, Bistoy Home Healthcare, 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:




601.31(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) and an interview with the agency's director of nursing and alternate administrator, the agency failed to ensure that Plan of Care (POC) contained frequency of visits for two (2) of five (5) CR's reviewed (CR ' s # 2 and 4).

Findings Include:

A review of clinical records (CR) was conducted on May 14, 2024 starting at 9:30 am.

CR#2 SOC (start of care): 11/9/23, contains POC. " Orders and Goals " reads, " Skilled Nursing Orders - Order: 1. To support patient with respiratory problem. teach about respiratory care. Oxygen safety. Monitor blood pressure. Goal: 1. Patient will be able to care for self and verbalized oxygen safety at home. " The orders did not contain frequency and duration of visits.

CR#4 SOC: 11/16/23, contained POC. " Orders and Goals " reads, " Skilled Nursing Orders - Effective date: 11/16/23. Order: Observation and assessment of vital signs to monitor: respiratory status, gastrointestinal status, cardio pulmonary status, integumentary status, pain management, endocrine status, neurological status, Renal/genitourinary status. Goal: patient will be free of exacerbation from (left blank) within 60 days. Effective date: 11/16/23. Order: observe and assess ability caregiver/family to provide the care for patient. Goal: patient will receive assistance needed for care during certification period." The orders did not contain frequency and duration of visits.

A review of agency's policy titled, "Care Plan - Plan of Care Requirements" was conducted on May 22, 2024 at approximately 12 pm and revealed the following: The policy reads in part, "statement of standard: ... The individualized plan of care includes the following: ... 5. The frequency and duration of visits to be made..."

An interview with the agency's director of nursing and alternate administrator on May 21, 2024, starting at 2:30 PM confirmed the above findings.






Plan of Correction:

For CR#2 and CR#4
Action Plan 601.31(b)
What action was taken to correct the deficiency cited?
(1.) A 1:1 Education was provided to the clinician who developed the plan of care for clinical records cited in the survey. The clinician was given education on how to develop the plan of care and provided with examples for future reference, including all elements per requirement of 28 PA. Code, Part IV, Health facility, Subpart G. Chapter 601. This clinician was also educated on how a correct MD order is written with an example from a chart with clearly define orders. This clinician POC development plan will be audited by the Quality Assurance Department: Audits will include all charts for the first 3 weeks with remediation as needed, then any new chart plus 75% for 3 weeks, and any new chart plus 50% for 3 weeks until the clinician is at 100%.
(2). All clinical staff will be re-educated on regulations, Pennsylvania State requirement, and company policies relating to the required elements of the individualized plan of care. The clinical staff will be educated on the development of the plan of care, including (1). All pertinent diagnoses: (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 measure, (xi)instructions for timely discharge or referral, and (xii) any other appropriate items. All clinical staff will be given education on how to develop the plan of care, including all requirements per PA. Code, Part IV, Health facility, Subpart G. Chapter 601. POC development for all clinicians will be audited by the Quality Assurance Department for 100% for 3 weeks, then 75% for 3 weeks, and 50% ongoing until all POC Development meets 100% of 28 PA. Code, Part IV, Health facility, Subpart G. Chapter 601 requirements.
(3). All future clinical staff will be educated on PA regulations and the company policies relating to the required elements of the individualized plan of care. All future clinical staff will be educated with sample well defined MD order, and a sample well-developed Plan of Care. Patient POC charts will be audited 100% after the clinician finish the documentation, education will be provided when needed, and corrections will be made when necessary. 100% of POC charts will also be audited monthly and quarterly. Deficiencies and or accuracy will be reported to the Quality Assurance Department.
Who at BisToy HHC is responsible for implementing the corrective action? Director of Nursing and the Quality Assurance Department.
(4). What is the monitoring process that BisToy HHC will put into place to ensure the implementation and effectiveness of the corrective action plan?
100% of the Plans of Care will be audited for 3 weeks, then 75% for 3 weeks, and 50% will be ongoing until all POC Development meets 100% of Pennsylvania requirement (28 PA. Code, Part IV, Health facility, Subpart G. Chapter 601). The Director of Nursing will report the tracking and trending of the audit, corrective actions, and education activities to the Quality Assessment Performance Improvement Committee (QAPI) beginning Q2, 2024. The action plan will be monitored by the Director of Nursing, Administrator, CEO, and the governing body.
(5). When will the corrective action be implemented? 06/17/2024



Initial Comments:


Based on the findings of an onsite unannounced home health agency state re-licensure survey conducted on on May 13, 2024 through May 14, 2024 and offsite on May 21, 2024 through May 22, 2024, Bistoy Home Healthcare, 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 onsite unannounced home health agency state re-licensure survey conducted on May 13, 2024 through May 14, 2024 and offsite on May 21, 2024 through May 22, 2024, Bistoy Home Healthcare, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: