Initial Comments:
Based on the findings of an unannounced onsite Medicare complaint survey completed December 23, 2024, Ahc Home Health and Hospice of Lehigh Valley was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.50(c)(9) ELEMENT State toll free HH telephone hotline Name - Component - 00 Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs.
Observations:
Based on a review of agency policy, a review of the patient admission handbook, and an interview with the agency Administrator, the agency failed to ensure the patient was advised of the state toll free home health telephone hot line (1-800-254-5164), its contact information, its hours of operation, and that its purpose is to receive complaints or questions about home health agencies for one (1) of one (1) patient admission handbooks reviewed (Patient Handbook #1).
Findings include:
Agency policy/procedure reviewed on December 23, 2024 at approximately 12:00 p.m. Policy 'Patient Bill of Rights' 'Procedure' section (L) states "Receive in writing, prior to the start of care, the telephone numbers for the State Home Health Hotline ..., including hours of operation, and the purpose of the hotline/s to receive complaints or questions about the organization. ..."
A review of the patient admission handbook was conducted on December 23, 2024 at approximately 11:00 a.m. revealed the following:
Patient Handbook #1: The 'Patient Handbook' page #9 states ".... 'State Hotline' (wrong phone number listed). ..." Page #13 states "To file a complaint to the State by calling their hotline. ....(wrong number listed).
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure that patients are advised of the state toll free home health telephone hot line (1-800-254-5164), its contact information, its hours of operation, and that its purpose is to receive complaints or questions about home health agencies. The agency will audit 100% of all new patient handbooks to ensure that the patient and the patient's legal representative (if any) are provided written notice of the state toll free home health telephone hot line (1-800-254-5164), its contact information, its hours of operation, and that its purpose is to receive complaints or questions about home health agencies. The contact information will be updated with the supplier and new handbooks ordered to ensure accurate information is being provided moving forward. The Administrator or appropriate designee will review contact information annually and as needed with changes to verify continued accuracy.
484.60(a)(1) STANDARD Plan of care Name - Component - 00 Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan.
Observations:
Based on a review of agency policy, a review of the clinical record, and an interview with the agency Administrator, the agency failed to ensure visits or a treatment or service as required by the plan of care was conducted as ordered for one (1) of one (1) clinical records (CR) reviewed (CR#1).
Findings include:
Agency policy/procedure reviewed on December 23, 2024 at approximately 12:00 p.m. Policy 'Missed Visits' 'Procedure' section (2) states "If a visit is missed and not rescheduled the clinician will: (A) Notify the physician and clinical supervisor of the missed visit and the reason for the missed visit."
A review of CRs was conducted on December 23, 2024 at approximately 11:30 a.m. The patients start of care (SOC) is listed below.
CR#1 SOC 09/10/24: Patients certification of the Plan of Care for the period of 11/09/24 - 01/07/24 reviewed. 'Orders/Treatments' include but is not limited to orders for a physical therapist (1week3: PT maintenance beginning during week of 11/15/24 - Ending on 11/30/24).
The week of 11/10/24-11/16/24 physical therapy conducted 0/1 visits. No documentation provided of the agency notifying the physician of the missed visit.
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure that patients receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. Agency Administrator and Clinical Director will ensure staff members will be educated to complete appropriate physician or allowed practitioner notification with all missed visits and follow up with correct documentation. The agency will audit 25% of all active patient records until a 95% target threshold is met. Once the threshold is met, the agency Administrator and Clinical Director will continue to audit 10% of patient records quarterly.
484.70(b)(1)(2) STANDARD Infection control Name - Component - 00 Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include:
(1) A method for identifying infectious and communicable disease problems; and
(2) A plan for the appropriate actions that are expected to result in improvement and disease prevention.
Observations:
Based on a review of agency policy, a review of employee files, and an interview with the agency Administrator, the agency failed to ensure tuberculosis (TB) screening was conducted upon hire, per policy, for two (2) out of five (5) employee files (EF) reviewed (EF#1, EF#3).
Findings Include:
Policy 'Categories/Qualifications of Personnel/ 'Health Requirements' section (1) states "Personnel with Patient Contact: ..... personnel must have a TST (tuberculin skin test) or show evidence that there is no active Tuberculosis in the past 12 months (by providing a copy of a negative TST taken within the past 12 months) prior to providing care. Documentation of these tests will be maintained in the personnel health file." (Note: This policy is not in accordance with CDC TB testing recommendations, which include, but is not limited to, utilizing the two-step TST method.)
A review of EFs was conducted on December 23, 2024 at approximately 10:00 a.m. The employees date of hire (DOH) is listed below.
EF#1 DOH 08/27/24: No documentation of TB testing upon hire.
EF#3 DOH 09/23/24: No documentation of TB testing upon hire.
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. The agency Administrator and Clinical Director will ensure employee files are in compliance with CDC recommendations with baseline tuberculin skin testing (TST). Initial / baseline two-step skin testing or blood testing and annual symptom assessments will be maintained in the personnel health file moving forward. The target threshold is 95%. Once the threshold is met, the agency administrator will continue to audit 50% of personnel files annually.
Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed December 23, 2024, Ahc Home Health and Hospice of Lehigh Valley was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
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 agency policy, a review of employee files, and an interview with the agency Administrator, the agency failed to ensure employee orientation was provided. per policy, for three (3) out of five (5) employee files (EF) reviewed (EF#1 - EF#3); failed to ensure employee maintained current cardio pulmonary resuscitation (CPR) certification, per policy, for one (1) out of five (5) employee files (EF) reviewed (EF#2); failed to ensure employees were provided with job descriptions upon hire, per policy, for three (3) out of five (5) employee files (EF) reviewed (EF#1 - EF#3); and failed to ensure tuberculosis (TB) screening was conducted upon hire, per policy, for two (2) out of five (5) employee files (EF) reviewed (EF#1, EF#3).
Findings Include:
Agency policy/procedure reviewed on December 23, 2024 at approximately 12:00 p.m. Policy 'Orientation' 'Policy' states ".....All clinical personnel prior to being assigned to care must present documentation of current CPR certification. CPR certification must be renewed per American Heart Association guidelines." 'Procedure' section (9) states "A Personnel Orientation Checklist (See 'Personnel Orientation Checklist' Addendum 1-022.A) will be completed for all new personnel. New personnel will sign and date when their orientation has been completed. (10) The supervisor will sign and date the checklist when the personnel have completed all required activities." Policy 'Job Description' 'Procedure' section (2) states "At the time of hire, each individual will receive and sign a job description specific to his/her position." Policy 'Categories/Qualifications of Personnel/ 'Health Requirements' section (1) states "Personnel with Patient Contact: ..... personnel must have a TST or show evidence that there is no active Tuberculosis in the past 12 months (by providing a copy of a negative TST taken within the past 12 months) prior to providing care. Documentation of these tests will be maintained in the personnel health file." (Note: This policy is not in accordance with CDC TB testing recommendations, which include, but is not limited to, utilizing the two-step TST method.)
A review of EFs was conducted on December 23, 2024 at approximately 10:00 a.m. The employees date of hire (DOH) is listed below.
EF#1 DOH 08/27/24: No documentation provided of orientation being provided per policy. Documentation provided of a job description being signed by the employee late on 09/23/24. No documentation of TB testing upon hire.
EF#2 DOH 07/12/24: No documentation provided of orientation being provided, per policy. No documentation provided of the employee obtaining CPR recertification when the CPR certification expired on 09/2024 (issue date 09/17/22, renewal date 9/2024). Documentation provided of a job description being signed by the employee late on 09/04/24.
EF#3 DOH 09/23/24: No documentation provided of orientation being provided per policy. No documentation of a job description being provided to/signed by the employee. No documentation of TB testing upon hire.
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure that 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. The Administrator will audit current personnel files to be in compliance with agency policies including but not limited to documentation of orientation, current CPR, TB screening, and current job descriptions. The target threshold is 95%. Once the threshold is met, the agency administrator will continue to audit 50% of personnel files annually.
601.21(h) REQUIREMENT COORDINATION OF PATIENT SERVICES Name - Component - 00 601.21(h) Coordination of Patient Services. All personnel providing services maintain liason to assure that their efforts effectively complement one another and support the objectives outlined in the plan of treatment. (i) The clinical record or minutes of case conferences establish that effective interchange, reporting, and coordinated patient evaluation does occur. (ii) A written summary report for each patient is sent to the attending physician at least every 60 days.
Observations:
Based on a review of agency policy, a review of the patient clinical record, and an interview with the agency Administrator, the agency failed to ensure a written summary report for the patient was sent to the attending physician at least every 60 days for one (1) of one (1) clinical record (CR) recertification periods reviewed (CR#1).
Findings Include:
Agency policy/procedure requested on December 23, 2024 at approximately 12:00 p.m. No specific policy related to sending the physician a written summary at least every (60) days was provided.
A review of CRs was conducted on December 23, 2024 at approximately 11:30 a.m. The patients start of care (SOC) is listed below.
CR#1 SOC 09/10/24: Patients certification of the Plan of Care for the period of 09/10/24 - 11/08/24. Documentation provided of a written summary ("Plan of Care Summary") being sent to the physician late on 11/15/24 (67 days).
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure all personnel providing services maintain liaison to assure that their efforts effectively complement one another and support the objectives outlined in the plan of treatment. (i) The clinical record or minutes of case conferences establish that effective interchange, reporting, and coordinated patient evaluation does occur. (ii) A written summary report for each patient is sent to the attending physician at least every 60 days. The Clinical Director will audit 25% of active patient records to ensure documentation of a plan of care summary being sent timely is present. The target threshold is 95%. Once the threshold sf met, the agency will continue to audit 10% of all patient records quarterly.
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, a review of the clinical record, and an interview with the agency Administrator, the agency failed to ensure visits or a treatment or service as required by the plan of care was conducted as ordered for one (1) of one (1) clinical records (CR) reviewed (CR#1).
Findings include:
Agency policy/procedure reviewed on December 23, 2024 at approximately 12:00 p.m. Policy 'Missed Visits' 'Procedure' section (2) states "If a visit is missed and not rescheduled the clinician will: (A) Notify the physician and clinical supervisor of the missed visit and the reason for the missed visit."
A review of CRs was conducted on December 23, 2024 at approximately 11:30 a.m. The patients start of care (SOC) is listed below.
CR#1 SOC 09/10/24: Patients certification of the Plan of Care for the period of 11/09/24 - 01/07/24 reviewed. 'Orders/Treatments' include but is not limited to orders for a physical therapist (1week3: PT maintenance beginning during week of 11/15/24 - Ending on 11/30/24).
The week of 11/10/24-11/16/24 physical therapy conducted 0/1 visits. No documentation provided of the agency notifying the physician of the missed visit.
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure that patients receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. Agency Administrator and Clinical Director will ensure staff members will be educated to complete appropriate physician or allowed practitioner notification with all missed visits and follow up with correct documentation. The agency will audit 25% of all active patient records until a 95% target threshold is met. Once the threshold is met, the agency Administrator and Clinical Director will continue to audit 10% of patient records quarterly.
Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed December 23, 2024, Ahc Home Health and Hospice of Lehigh Valley was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE Photo Id Reg Name - Component - 00 Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent photograph of the employee, the employee's first name, the employee's title and the name of [the health care facility or employment agency.] any of the following: (i) The health care facility. (ii) The health system. (iii) The employment agency. (iv) The fictitious name of an entity under subparagraph (i), (ii) or (iii) which is registered with the Department of State under 54 Pa.C.S. Ch. 3 (relating to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows: (i) A Medical Doctor shall have the title "Physician." (ii) A Doctor of Osteopathy shall have the title "Physician." (iii) A Registered Nurse shall have the title "Registered Nurse." (iv) A Licensed Practical Nurse shall have the title "Licensed Practical Nurse." (v) All other titles shall be determined by the department. Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on December 23, 2024 at approximately 12:30 p.m. revealed the title of the employee was not as large as possible in block type occupying a one-half inch tall strip as close as practicable to the bottom edge of the badge. The employee title was approximately 1/8" font and was centered above the bottom 1/2" of the badge.
An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:As an agency we will ensure that (1) The photo identification tag shall include a recent photograph of the employee, the employee's first name, the employee's title and the name of [the health care facility or employment agency.] any of the following: (i) The health care facility. (ii) The health system. (iii) The employment agency. (iv) The fictitious name of an entity under subparagraph (i), (ii) or (iii) which is registered with the Department of State under 54 Pa.C.S. Ch. 3 (relating to fictitious names) or a successor statute. (2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge. (3) Titles shall be as follows: (i) A Medical Doctor shall have the title "Physician." (ii) A Doctor of Osteopathy shall have the title "Physician." (iii) A Registered Nurse shall have the title "Registered Nurse." (iv) A Licensed Practical Nurse shall have the title "Licensed Practical Nurse." (v) All other titles shall be determined by the department. Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency. (4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name. Agency Administrator and Clinical Director will update current employee badges and will update agency badge templates to meet all badge requirements. Agency administrator will audit badges annually to maintain compliance.
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