Initial Comments:
Based on the findings of an onsite home health agency state re-licensure survey conducted April 22, 2025, ATM Home Healthcare Services, 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 follow its policy that the governing body review and approve the annual program evaluation and annual review of all agency policies and procedures.
Findings include:
A review of agency policy titled, "Governing Body" conducted on April 22, 2025 at approximately 1:00 PM states, "The scope of responsibilities of the [Governing Body] includes but is not limited to:1. Decision making. 2. Appoint a qualified administrator. 3. Adopting and periodically review written bylaws or equivalent. 4. Establishing/approving written policies and procedures that govern operations. 5. Reviewing/approving written policies and procedures that govern operations annually. 6. Managing human resources. 7. Quality Assessment and Performance Improvement (QAPI). 8. Community needs planning, if applicable. 9. Overseeing management, operational plans, fiscal operations, and budget review of the agency...Governing body activities will be recorded in written reports and documented in the minutes of the governing body minutes..."
A review of the Governing Body meeting minutes was conducted on April 22, 2025 at approximately 12:00 PM. Meeting was held on February 8, 2025. Meeting minutes only included an Agenda for the meeting. There was no documentation in the meeting minutes that the governing body reviewed and approved the annual program evaluation, or all agency policies and procedures. Statement included in meeting minutes states, "All topics presented at PAC (Professional Advisory Committee) Meeting presented at PAC Meeting were accepted by [Administrator]." There was no indication of the topics presented in the PAC Meeting.
An interview with the administrator conducted on April 22, 2025, at approximately 1:00 PM confirmed the above findings.
Plan of Correction:All Governing Body minutes will contain minutes of all the topics discussed in the meeting to include appointments of Administrator, Alternate Administrator, Medical Director and Director of Nursing. Other topics may include annual program review with recommendations, future plans for growth and improvements and others.
The staff responsible for the correction are the Scribe, the Administrator and the member of the Governing Body.
To Administrator will make sure that the Scribe includes the entire minutes from the discussion before presenting to the Governing Body for review and approval. The Governing Body will not approve unless the minutes of the discussions are present.
The Administrator will be responsible in monitoring to ensure continuous compliance.
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 a review of agency policy, Professional Advisory Committee (PAC) Meeting Minutes, and an interview with the administrator, the agency failed to ensure there was documentation to show the PAC annually reviewed agency policies and the annual program evaluation.
Findings include:
Review of agency policy titled, "Professional Advisory Committee," (PAC) on April 22, 2025, at approximately 12:15 PM states, "Advisory Committee Duties is to: 1. Establish and annually review the Agency policies governing the scope of services offered, admission and discharge policies, medical supervision, clinical protocols, and plans of treatment, emergency care, clinical records, and personnel qualifications and program evaluation..."
A review of PAC Meeting Minutes was conducted on April 22, 2025, at approximately 12:10 PM. Meeting was held on February 7, 2025 and revealed no documentation the PAC reviewed and approved the agency policies or annual program evaluation.
An interview with the administrator conducted on April 22, 2025 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:All PAC meetings should contain minutes of each topic discussed. This topics may include review of policies and procedures, Quality Improvement projects, annual Program review with recommendations, clinical protocols and others
The staff responsible will be the Scribe and the Administrator. The Administrator will review the minutes given by the Scribe for completeness and accuracy. The Administrator will not accept if the minutes are not complete.
The Administrator will be responsible to ensure continuous compliance.
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 follow its policy to produce written documentation of all findings to present to the Adivisory Committee (PAC) and develop a plan for the results of the findings and implement corrections for any deficiencies.
Findings include:
A review of the agency policy titled "Annual Program Evaluation", conducted on April 22, 2025, at approximately 12:20 PM states, "Procedure: 2. Review and evaluate the extent to which agency's program is appropriate, effective, and efficient. 3. Evaluate policies and procedures. 4. Review the clinical program, to include review of personnel qualifications, infection control, supervision as well as patient complaints. 5. Perform a proactive approach for the improvement in the agency's operation. 6. Develop a plan for results of the findings and implement corrections for any deficiencies. 7. Produce a written documenation of all findings to be presented to the PAC..."
Review of documentation on April 22, 2023 at approximately 12:30 PM revealed:
There was no documentation of written findings of the completed annual program review to present to the Adivisory Committee (PAC) and no documentation of a plan for results of the findings and how to implement corrections for any deficiencies.
An interview with the administrator on April 22, 2025 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:All Annual Program review should be more comprehensive for presentation in the PAC Meeting. Program Review will include evaluation of care provided, improvement process or proactive approaches to be enforced fir a better service, Review of policies and updates if any, admissions and discharges and others.
The Administrator, clinical staff, office staff involved in daily operation.
The Administrator will evaluate program gathered from all staff and gather and evaluate recommendations. Administrator will make sure that Annual review is complete and clear before presenting to the PAC Meeting. Administrator will be responsible for continuous compliance.
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 review of clinical records (CR), policy and procedure, and an interview with the administrator, the agency failed to ensure that the registered nurse checked all medications to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy and to report any problems to the physician per agency policy for seven (7) of seven (7) CRs reviewed, (CR #1, 2, 3, 4, 5, 6, and 7).
Findings include:
A review of agency policy titled "Medication Reviewand Administration" conducted on April 22, 2025 at approximately 12:25 PM states, "A registered nurse (RN) or physical therapist (PT), Occupational Therapist (OT), or Speech-Language Pathologist (SLP) will complete the Drug Regimen Review as part of the comprehensive assessment. Qualified clinicians will review all medications that the patient is currentl using in order to identify any potential adverse effects and/or drug reactions and are accountable for evaluating the following, which includes but is not limited to: Ineffective drug therapy; Effectiveness of drug therapy; Significant drug side effects; Immediate desired effects; Unusual and unexpected effects; Significant drug interactions; Duplicate drug therapy; Noncompliance with drug therapy; Drug therapy currently associated with laboratory monitoring; Allergice reactions; and Changes in the patient's condition that contraindicate continued administration of the medication..."
A review of CRs was conducted on April 22, 2025 from approximately 9:45 AM to 11:00 AM.
Findings:
CR #1, Start of Care: 4/14/2025; Certification period reviewed 4/14/2025 to 6/12/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
CR #2, Start of Care: 3/15/2025; Certification period reviewed 3/15/2025 to 5/13/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
CR #3, Start of Care: 10/4/2024; Certification period reviewed 4/8/2025 to 6/7/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
CR #4, Start of Care: 3/13/2025; Certification period reviewed 3/13/2025 to 5/11/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
CR #5, Start of Care: 1/25/2025; Certification period reviewed 3/29/2025 to 4/9/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
CR #6, Start of Care: 9/17/2024; Certification period reviewed 3/16/2025 to 5/14/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
CR #7, Start of Care: 10/18/2024; Certification period reviewed 4/16/2025 to 6/14/2025; revealed no documentation that medications were assessed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for the above reviewed certification period.
An interview with the administrator conducted on April 22, 2022 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:All recertification visits should include reconciliation of medication and treatments, to identify duplicate therapy, drug interaction and effectivity of the treatment. All medications should be updated for any changes and documented and recorded. All staff responsible for the correction were informed, trained and instructed to record changes and reconciled medications in the clinical summary by the clinical manager.
The staff responsible for the correction are the Clinical manager and QA staff. QA staff will review and monitor records of all recertification visits and present findings to the Administrator and Clinical manager in the QA meeting.
The QA staff will monitor to ensure continuous compliance.
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 agency policies, clinical records (CR), and interview with the administrator, it was determined that the agency failed to follow its policies regarding documentation and submission of discharge summaries for two (2) of two (2) discharged CR's (CR #4 and 5).
Findings include:
A review of agency policy titled "Patient Transfer/Discharge" on April 22, 2025 at approximately 12:40 PM states, "A discharge summary will be completed, which includes but is not limited to: Date of discharge; Patient identifying information; The patient's physician or allowed practitioner's name and phone number; Diagnosis; Reason for discharge; A brief description of care/services provided; Patient's medical and health status at the time of discharge; and Any instructions given to the patient or responsible party at discharge..."
A review of CR's was conducted on April 22, 2025 from approximately 9:45 AM to 11:00 AM revealed the following:
CR #4, Start of Care: 3/13/2025. Discharge Date: 4/9/2025. Certification period reviewed: 3/13/2025 through 5/11/2025. There is no documentation of a discharge summary or that a discharge summary was sent to the physician.
CR #5, Start of Care: 1/25/2025. Discharge Date: 4/9/2025. Certification period reviewed: 3/29/2025 through 4/9/2025. There is no documentation of a discharge summary or that a discharge summary was sent to the physician.
An interview with the administrator on April 22, 2025 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:All patients being discharged should have a Discharge Summary, with a brief description of the care received from the agency, date of discharge, reason of discharge and all teachings given to the patient of family.
The person responsible is the staff providing care, the clinical manager, QA staff and Administrator.
QA and clinical manager will review and monitor all discharged patients record.
QA will present any findings to the meeting with the clinical manager and Administrator.
QA staff will be responsible for checking to ensure continuous compliance.
Initial Comments:
Based on the findings of an onsite home health agency state re-licensure survey conducted on April 22, 2025, ATM Home Healthcare Services, 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 home health agency state re-licensure survey conducted on April 22, 2025, ATM Home Healthcare Services, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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