Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted February 13, 2024 through February 14, 2024, VNA of Greater Philadelphia, 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:
601.22(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 an interview with the agency administrator and review of agency policy, the agency failed to ensure there was documentation to show the professional advisory committee met annually to participate in the evaluation of the agency's program and advise the agency on professional issues.
Findings include:
Review of agency policy No.8-030, "Professional Advisory Committee" on February 14, 2024, at approximately 12:08 p.m states, "Governing Body will appoint a multidisciplinary Professional Advisory Committee (PAC)....The committee will meet quarterly, or more often as needed, and minutes each meeting will be recorded. The committee is authorized by the Governing Body to advise the organization on professional issues......."
Review of policy manual and meeting minutes on February 14, 2024, at approximately 11:52 a.m. revealed no evidence of a Professional Advisory Committee (PAC) meeting being conducted in 2022 or 2023.
Interview with the administrator on February 14, 2024, at approximately 12:23 p.m. confirmed that professional advisory committee meetings have not been conducted in accordance with agency policy.
Plan of Correction:A Professional Advisory Committee (PAC) meeting will be held quarterly, beginning the 2nd quarter of 2024 and continuing from thereon. Scheduling and staffing of PAC will be handled by the Director of Quality and Education. The professional advisory committee is currently being assembled and will consist of RN with homecare or community health experience, PT, OT, ST, and a social worker. The community member that is neither an owner nor an employee of the organization and a practicing physician. Director of Quality and Education will house and manage all documentation of PAC meetings and attendance along with minutes. The first PAC meeting will be completed by April 14, 2024.
601.22(d) REQUIREMENT
CLINICAL RECORD REVIEW
Name - Component - 00
601.22(d) Clinical Record Review. At
least quarterly, appropriate health
professionals, representing at least
the scope of the program, review a
sample of both active and closed
clinical records to assure that
established policies are followed in
providing services (direct as well as
services under arrangement). There is
a continuing review of clinical
records for each 60-day period that a
patient receives home health services
to determine adequacy of the plan of
treatment and appropriateness of
continuation of care.
Observations:
Based on a review of facility documentation, review of policy and procedure, and interview with administrator, the facility failed to ensure at least quarterly, appropriate health professionals, representing at least the scope of the program, review a sample of both active and closed clinical records to determine whether established policies are followed in furnishing services directly or under arrangement.
Findings include:
Review of policy titled: No. 3-007, "Clinical Record Review" on February 14, 2024, at approximately 11:04 a.m states, "Clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered is reliable, timely, valid and accurate......."
Review of "Clinical Record Review" documentation on February 14, 2024, at approximately 10:50 a.m. revealed there was no documentation of quarterly record reviews for the first, third or fourth quarter of 2023.
Interview with administrator on February 14, 2024, at approximately 11:10 a.m. confirmed the above finding.
Plan of Correction:RN Educator will conduct quarterly review of 30 client charts of RN (7 active, 8 closed) and 15 client charts of LPN (7 active and 8 closed) per quarter, beginning in the first quarter of 2024 and continuing through each quarter. RN Educator will use the clinical record evaluation tool designed for quarterly audits and will be overseen by Director of Quality and Education. Audits that reveal trends will be reported at QAPI meetings and discussed to prepare a performance improvement plan. This auditing process has already been implemented, as of March 1, 2024.
During times of low productivity, clinicians who come into the office will also be given a list of active and inactive clients to perform clinical record reviews as part of their contribution to quality improvement and peer evaluation. These will be tracked in a separate binder and kept in the Director's of Quality and Education office and information gained from these reviews will also be shared at QAPI meetings.
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 upon clinical record review, and an interview with the Administrator, it was determined the agency failed to provide services according to the plan of care for five (5) of ten (10) clinical records reviewed. (CR # 1, 2, 3, 5 and 9).
Findings include:
Review of agency policy No.1-026 titled, "Missed Visits" on February 14, 2024 at approximately 10:42 a.m. states, "Missed visits will be communicated to the clinical supervisor and the patient's physician.... A missed visits will be documented in the clinical record".
Clinical records were reviewed on 2/13/24 at approximately 10:12 a.m. and on 2/14/24 at approximately 9:30 a.m. and revealed the following:
CR #1 (Start of Care: 1/12/24). Certification period reviewed: 1/12/24-3/11/24. Physical Therapy ordered for 1/14/2024 one (1) time weekly for three (3) weeks, then two (2) times weekly for two (2) weeks, then one (1) time weekly for three (3) weeks. Physical Therapy ordered change for 1/17/2024 one (1) time weekly for one (1) week, then two (2) times weekly for four (4) weeks, then one (1) time weekly for three (3) weeks.
During the week of 2/4/24-2/10/24 there was one (1) missed physical therapy visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care.
CR # 2 (Start of Care: 1/2/24). Certification period reviewed: 1/2/24-3/1/24. Skilled Nursing ordered for two (2) times a week for one (1) week, then one (1) time a week for four (4) weeks, then two (2) times a week for one (1) week, then two (2) times a week for two (2) weeks, then one (1) time a week for one (1) week. During the week of 1/21/24-1/27/24 there was one (1) missed skilled nursing visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care.
CR# 3 (Start of Care: 11/3/23). Certification period reviewed: 1/2/24-3/1/24. Skilled Nursing ordered for one (1) time a week for one (1) week, then two (2) time a week for three (3) weeks, then one (1) time a week for five (5) weeks. During the week of 1/21/24-1/27/24 there was one (1) missed skilled nursing visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care. Home Health Aide order for two (2) time a week for two (2) weeks, then one (1) time a week for five (5) weeks. During the week of 1/2/24-1/6/24 there was one (1) missed home health aide visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care.
CR#5. (Start of Care: 1/9/24). Certification period reviewed: 1/9/24 -3/8/24. Skilled Nursing ordered for two (2) times a week for eight (8) weeks, then one (1) time a week for one (1) week. During the week of : 1/14/24-1/20/24 there was one (1) missed skilled nursing visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care.
CR# 9. (Start of Care: 12/18/23). Certification period reviewed: 12/18/23-2/18/24. Occupation Therapy ordered for one (1) time a week for one (1) week, then two (2) times a week for four (4) weeks, then one (1) time a week for one (1) week. During the week of 12/24/23-12/30/23 there were two (2) missed occupational therapy visits. There was no documented evidence of physician notification and/or physician order to revise the plan of care.
An interview the Administrator on 2/14/24 at approximately 10:49 a.m. confirmed the above findings.
Plan of Correction:All clinicians will be educated on the process of notifying the physician and documenting evidence of physician notification and/or physician order to revise the plan of care in an all staff meeting on March 6, 2024. This was completed for all clinicians present on 3/6/2024 meeting.
Once all clinicians have been educated on 3/6/24 via all staff meeting and a follow-up email with notes about the meeting, an audit will be conducted quarterly, beginning on April 1, 2024, on missed visits by the scheduling and clinical management teams, collaboratively. This will consist of running the Missed Visits report in HCHB for the previous quarter, and randomly choosing 10 patients/clinicians to audit.
If found to be out of compliance, the clinician will be educated and asked to notify the physician or obtain a physician order to revise the plan of care accordingly. The goal is to achieve 100% compliance on missed visit audits for 2 quarters consecutively, before ending the audit.
We will return to the audit 2 quarters after reaching our goal, to be sure that we have maintained compliance with notifying physicians of missed visits.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on February 13, 2024 through February 14, 2024, VNA of Greater Philadelphia., 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 state re-licensure survey conducted February 13, 2024 through February 14, 2024, VNA of Greater Philadelphia, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|