Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed January 18, 2024, St. Lukes Home Health 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 agency policy/procedure, employee files, and an interview with the agency Quality Manager, agency failed to ensure criminal history clearances were conducted, as per policy, for three (3) of three (3) employee files (EF) reviewed (EF#8 - EF#10).
Findings Include:
Agency policy/procedure was reviewed on January 17, 2024 at approximately 1:00 p.m. Policy 'Criminal and Child Abuse History Clearances' section (III) 'Procedure' (1)(d) "Eligibility for employment or transfer will depend on the candidate obtaining in timely manner the required criminal history clearance including the Pennsylvania State Police Criminal Record Clearance, the Pennsylvania Child Abuse History Clearance, and the FBI fingerprint Based Criminal History Clearance. .... (4) ...... As required by the CPSL, screenings are required to be renewed sixty (60) months from the most recent completion...."
A review of EFs was conducted on January 17, 2024 at approximately 12:00 p.m.
EF#8, date of hire 08/03/15: Documentation provided of initial/upon hire criminal checks. Pennsylvania State Police 'Response for Criminal Record Check' conducted on 07/08/15.
(Most recent 60 month recertification conducted late on 10/26/20). 'Pennsylvania Child Abuse History Clearance' conducted on 07/06/15. (Most recent 60 month recertification conducted late on 12/08/20). 'Pennsylvania Department of Human Services' conducted on 07/30/15. (Most recent 60 month recertification conducted late on 11/24/20).
EF#9, date of hire 08/28/17: Documentation provided of initial/upon hire criminal checks. Pennsylvania State Police 'Response for Criminal Record Check' conducted on 07/31/17.
(Most recent 60 month recertification conducted late on 12/21/23). 'Pennsylvania Child Abuse History Clearance' conducted on 08/09/17. (Most recent 60 month recertification conducted late on 12/14/23). 'Pennsylvania Department of Human Services' conducted on 08/11/17. (Most recent 60 month recertification conducted late on 12/14/23).
EF#10, date of hire 07/17/17: Documentation provided of initial/upon hire criminal checks. Pennsylvania State Police 'Response for Criminal Record Check' conducted on 06/14/17.
(Most recent 60 month recertification conducted late on 11/01/22). 'Pennsylvania Child Abuse History Clearance' conducted on 07/05/17. (Most recent 60 month recertification conducted late on 10/19/22). 'Pennsylvania Department of Human Services' conducted on 06/29/17. (Most recent 60 month recertification conducted late on 10/20/22).
An interview conducted with agency Quality Manager on January 17, 2024 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. For 601.21(f) Personnel Policies, Agency will ensure the required CPSL criminal history clearances will be renewed prior to sixty months from the most recent completion.
2. Agency will audit all current employees for compliance with completion of CPSL screening within the 60 month requirement.
3. Notice of pending expiration of CPSL screening and need for renewal will be sent via email to identified employees and their managers, 90, days, 60 days, 30 days, and 14 days prior to the 60 month expiration date for completion. Employees who do not meet the requirement will not be permitted to work until completion.
4. Agency will conduct an initial audit of all applicable employee records to identify upcoming expiration dates and then will conduct monthly audits of all employee records who are 90 days, 60 days, 30 days, and 14 days from expiration to ensure 100% compliance with CPSL screening regulation.
5. Corrective action will be completed by 3/1/2024.
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/procedure, review of clinical records, and an interview with the agency Quality Manager, agency failed to ensure agency staff review all patient medications for two (2) of two (2) patient clinical records reviewed (CR#4, CR#7).
Findings Include:
Agency policy/procedure was reviewed on January 17, 2024 at approximately 1:00 p.m. Policy 'Comprehensive Assessment and Reassessment of Patients' section (II) 'Procedure' (3) states"A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, ....."
An interview was conducted with the agency Quality Manager on 01/17/24 at approximately 1:00 p.m. Per the Quality Manager, medications are reviewed by a licensed nurse but this is not stated in the agency policy. The Quality Manager stated we follow the COP's (Conditions of Participation/federal regulation set) and a licensed nurse reviews all patient medications.
(Note: The federal home health regulation set '484.55.(c)(5)' interpretive guidance specifies "In rehabilitation therapy only cases, the patients therapist must submit a list of patient medications, which the therapist must collect during the comprehensive assessment, to an HHA nurse for review. ....")
CR#4, start of care 12/22/23: A Physical Therapist (Employee #2) completed the patients comprehensive assessment on 12/22/23. Documentation provided of a registered nurse (Employee #11) calling the patient for "Med review" on 12/27/23, "No answer. Message left....." Documentation provided of a registered nurse (Employee #11) calling the patient calling the patient for "Med review" on 01/10/24, "No answer. Message left ..." Documentation provided of a registered nurse (Employee #12) completing a home visit on 01/14/24. The home visit included a medication review. (Medication review conducted 23 days after patient start of care).
CR#7, start of care 12/01/23: A Physical Therapist (Employee #13) completed the patients comprehensive assessment on 12/01/23. Documentation provided of a registered nurse (Employee #11) calling the patient for "Med review" on 12/04/23, "...wife who answered but stated it was not a good time...." Documentation provided of a registered nurse (Employee #11) calling the patient for "Med review" on 12/13/23, "No answer. Left message ..." Documentation provided of a registered nurse (Employee #11) calling the patient for "Med review" on 01/08/24, "No answer. Left message ..." (Medication review not completed as of 01/17/24, 45 days after patient start of care).
An interview conducted with agency Quality Manager on January 17, 2024 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. For 601.31(d) Conformance with Physician's orders, Agency will ensure that all patients will have a comprehensive medication review completed by a Registered Nurse.
2. Agency will audit 100% of all therapy only cases for compliance that a comprehensive medication review was completed by a Registered Nurse.
3. The Comprehensive Assessment and Reassessment policy will be updated to reflect that a Registered Nurse will perform the medication review on all therapy only cases. The RN (s) who will be assigned to perform the medication review will be educated on the policy and updated process.
4. A Quality Resource Clinician or RN will review 100% of Therapy only episodes monthly until 95% compliance with medication review is achieved. Once 95% compliance is achieved for a quarter, a Quality Resource Clinician or RN will review 10% of Therapy Only episodes to ensure 95% compliance is maintained.
100% review will resume if 95% compliance is not maintained.
5. Corrective action will be completed by 3/1/2024.
601.35(a) REQUIREMENT
SELECTION OF AIDES
Name - Component - 00
601.35(a) Selection of Aides. Home
health aides are selected on the basis
of such factors as sympathetic
attitude toward the care of the sick,
ability to read, write, and carry out
directions, and maturity and ability
to deal effectively with the demands
of the job. Aides are carefully
trained in assisting patients to
achieve maximum self-reliance,
principles of nutrition and meal
preparation, the aging process and
emotional problems of illness,
maintaining a clean, healthful, and
pleasant environment, changes in
patient's condition that should be
reported, work of the agency and the
health team, ethics and
confidentiality, and recordkeeping.
Home Health Aid Training. All home
health aides have completed a minimum
of 60 hours of classroom instruction
prior to or during the first 3 months
of employment.
They are closely supervised to assure
their competence in providing care.
Observations:
Based on a review of agency policy, review of employee files, and an interview with the agency Quality Manager, agency failed to ensure home health aide completed a minimum 60 hours of classroom instruction prior to or during the first 3 months of employment for one (1) out of one (1) home health aide employee files (EF) reviewed (EF#6).
Findings Include:
Agency policy/procedure was reviewed on January 17, 2024 at approximately 1:00 p.m. Policy 'Home Health Aide Service' (III) 'Procedure' (12) states 'Preparation of Medicare Certified HHA's' (a) "Each HHA will participate in a 75 hour educational program consisting of classroom and practical skills training." (Note: This policy does not specifically state a minimum of 60 hours of classroom instruction, as stipulated in the regulations.)
A review of EFs was conducted on January 17, 2024 at approximately 12:00 p.m.
EF#6 DOH 02/20/23: Documentation provided of 'Ultimate Medical Academy Online' (Tampa, Florida) with 'Original Start Date' of 08/16/21 and a 'Date Awarded' of 06/05/22 with 'Credits Earned:' "57", a one page document labeled 'Class' with (9) classes with dates ranging from 02/23/23 to 12/6/23, 'Hours' "10 hours, 2023", a 'Home Health Aide (HHA) Assessment' test dated 02/23/23 and labeled "2.5 hours with review", an 'infection Control/Employee Health Self-Study Packet Orientation' 'Post Test' dated 02/20/23 labeled "1.5 hours", a 'VNA of St. Lukes Day 1 VNA Orientation' dated 2-02/20/23 labeled "8 hours", (2) online certificates dated 05/25/23 totaling "0.47 hours."
A one page form '(EF#6) Education' labeled "2/20/23-5/20/23" summarized employee training and was labeled 19.43 total hours plus 57 hours schooling = 76.43 hours."
No documentation provided of the employee completing a minimum of (60) hours of classroom instruction , to include self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes in patient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and record keeping prior to or during the first 3 months of employment.
An interview conducted with agency Quality Manager on January 17, 2024 at approximately 2:30 p.m. confirmed the above findings.
Plan of Correction:1. For 601.35 (a) Selection of Aides, Agency will ensure all Home Health Aides have completed the minimum 60 hours of classroom instruction prior to hire at the agency. EF#6 will have completed the required hours prior to resuming job duties.
2. Agency will audit 100% of all Home Health Aide personnel files for compliance of the required 75 hours of training as required by CMS Conditions of Participation. Personnel that do not meet this requirement, will be removed from direct patient care until the 75 hours of required training is completed.
3. The Human Resource staff and Patient Care Managers will be reeducated to ensure the applicant has the 75 hours of required classroom instruction.
4. The hiring manager of the Home Health Aide will validate the 75 hours of education. Required education criteria will be added to the Home Health Aide Orientation Checklist. Orientation checklists will be audited quarterly by the Education Coordinator and the results reported to the Vice President of Patient Care Services.
5. Corrective action will be completed by 3/1/2024.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed January 18, 2024, St. Lukes Home Health was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart A. Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed January 18, 2024, St. Lukes Home Health was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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