Initial Comments:Based on the findings of an unannounced, onsite Medicare recertification survey conducted April 1 through April 4, 2025, Commonwealth Home Health &; Hospice of Wilkes-Barre was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the findings of an unannounced, onsite Medicare recertification survey conducted April 1 through April 4, 2025, Commonwealth Home Health &; Hospice of Wilkes-Barre 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:
484.60(e)(3) ELEMENT
Treatments and therapy services
Name - Component - 00
Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services.
Observations:
Based on the review of agency policies/procedures, documentation, clinical records and observation, and based on interview with the Administrator (Employee #12), the agency failed to ensure patient-specific wound care instructions had been provided in writing to two (2) of four (4) patients for whom wound care was performed by agency nursing staff. (Patients #7 and #8)
Findings include:
On April 4, 2025 at approximately 2:37 PM, review of the agency policy titled "Coordination of Care, From Admit to Discharge" revealed the following under "Procedure":
7. Coordination of care with patient and caregivers:
Written instructions obtained from the plan of care will be provided to the patient and caregiver outlining...
c. Treatments to be administered by agency staff...
d. Pertinent instructions related to the patient's care and treatments that the agency will provide, specific to the patient's needs...
Patient #7: Between April 3, 2025 at approximately7:43 AM and April 4, 2025 at approximately 7:45 AM, review of the clinical record revealed skilled nursing (SN) is to perform the following wound care as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/15/2025 through 04/15/2025. Cleanse left second toe wound with normal saline solution, apply Allevyn (foam wound dressing) using clean technique, two (2) time a week.
During home visit conducted on 04/03/2025, the RN (Employee #5) performed the above referenced wound care. Review of the patient's admission folder/folder failed to reveal instructions regarding the above referenced wound care orders had been provided to the patient in writing.
Patient #8: Between April 3, 2025 at approximately 3:17 PM and April 4, 2025 at approximately 7:59 AM, review of the clinical record revealed SN is to perform the following wound care as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/28/2025 through 04/28/2025. Cleanse right outer ankle wound with normal saline solution, pat dry with gauze, with a sterile Q-Tip apply Santyl (wound treatment) directly into the wound, cover with dry sterile dressing and secure with tape daily.
During home visit conducted on 04/03/2025 at approximately 11:35 AM, the RN (Employee #6) performed the above referenced wound care. Review of the patient's admission folder/folder failed to reveal instructions regarding the above referenced wound care orders had been provided to the patient in writing.
During interview conducted on April 4, 2025 at approximately 2:58 PM, the Administrator confirmed there was no documentation which provided evidence patient-specific wound care instructions had been provided to the above identified patients in writing.
Plan of Correction:Patient specific wound care instructions provided to patient's # 7 and 8.
During a mandatory meeting to be held on 4/22/2025, the Executive Director (ED) will instruct all clinical staff on the process of coordination of interventions with the patient/caregiver with an emphasis on ensuring specific wound care instructions are provided to the patient/caregiver referencing Policy 2.1.017 Coordination of Care, From Admit to Discharge and the Patient Written Instructions and Legal Representative Notice of Rights Job Aid.
Written information obtained from the plan of care will be provided to the patient and caregiver outlining treatments to be administered by staff or contract workers, including therapy services and pertinent instructions related to the patient's care and treatments that the agency
will provide, specific to the patient's needs, to include wound care.
The patient will receive a copy of the Patient Written Instructions Report which includes the visit frequency/schedule, medications, and treatments via mail once the plan of care is approved.
On the admission visit, the clinician will inform the patient and caregiver that they will receive written patient instructions in the mail and instruct them to keep the instructions with the home folder for reference.
On each subsequent visit, the clinician will review the home folder to ensure the Patient Instructions Report is
maintained and up to date, and inform the patient and caregiver of any changes to the plan of care, and manually edit the Patient Instruction Report for any visit frequency, medication, and/or
treatment changes.
Beginning the week of 4/27/2025, the Executive Director and/or Patient Care Manager will conduct 2 home visits weekly to ensure that the patient/caregiver have been given written instructions on wound care instruction in the home.
This monitoring will be done for 12 weeks and until 100% compliance achieved x 4 consecutive weeks.
484.110(a)(2) ELEMENT
Interventions and patient response
Name - Component - 00
All interventions, including medication administration, treatments, and services, and responses to those interventions;
Observations:
Based on the review of agency policies/procedures and clinical records, and based on interview with a registered nurses (RN-Employee #11) and the Administrator (Employee #12) , the agency failed to ensure documentation was maintained in the clinical record which provided evidence peripherally inserted central catheter (PICC-intravenous) assessment was completed in accordance with agency policy/procedure for two (2) of two (2) patients for whom PICC line dressing changes were completed by agency RN's. (Patients #11 and #12)
Findings include:
On April 4, 2025 at approximately 11:45 AM, review of the agency policy titled "Dressing Change Procedure for Central Venous, Midline, and Peripheral Inserted Central Catheters" revealed the following under "Procedure":
8. Inspect catheter, catheter exit site, and...
c. Obtain upper arm circumference...
d. Measure external length of catheter...
16. Document the procedure in the patient's record
On April 4, 2025 at approximately 2:34 PM, review of the agency policy titled "Patient Assessment, Initial and Reassessment" revealed the following under "Procedure":
NOTE: It is acceptable to use a general skill nursing progress note instead of an age-specific progress note, when the nurse deems appropriate...
6. Patient status is reviewed on an ongoing basis...
Patient #11: On April 4, 2025 between the approximate times of 8:40 AM and 11:45 AM, review of the clinical record revealed skilled nursing (SN) is to perform weekly PICC line dressing changes and observe and assess the PICC site as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 03/19/2025 through 05/17/2025.
Review of SN visit note report documentation dated 03/24 and 03/31/2025 revealed the RN (Employee #11) changed the right upper arm PICC line dressing but there was no documentation in the clinical record which provided evidence the RN assessed the circumference of the right upper arm nor the external length of the PICC line on the aforementioned dates.
During interview conducted on April 4, 2025 at approximately 2:45 PM, the RN (Employee #11) reported PICC line assessment on the aforementioned dates included measurement of the right upper arm circumference and external PICC line length. RN reported the electronic SN note previously included an area to document the arm circumference and external PICC line length but said area is no longer available in the electronic SN visit note which resulted in the PICC line assessment findings not being documented on the electronic SN visit note report.
Patient #12: On April 4, 2025 at approximately 8:58 AM, review of the clinical record revealed SN is to perform weekly PICC line dressing changes and that patient goals include for patient to remain free of infusion device complications as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/02/2025 through 04/02/2025.
Review of the recertification visit note report dated 04/01/2025 revealed the RN (Employee # 5) changed the right upper arm PICC line dressing but there was no documentation in the clinical record which provided evidence the RN assessed the circumference of the right upper arm nor the external length of the PICC line.
During interview conducted on April 4, 2025 at approximately 2:58 PM, the Administrator confirmed a recent software upgrade resulted in the elimination of the area to document PICC line assessment findings for arm circumference and external line length and that the clinical records of the above identified patients failed to include documentation which provided evidence PICC line assessment was performed in accordance with agency policy/procedure on the aforementioned dates.
Plan of Correction:Patient # 11 has been discharged from home health services.
Patient # 12 midarm circumference and external catheter length assessed and documented on subsequent visits when Peripherally Inserted Central Catheter (PICC) dressing was changed.
During a mandatory meeting to be held on 4/22/2025, the Executive Director will instruct all clinical staff on the process of complete assessment of the PICC line with emphasis on obtaining midarm circumference and external catheter length with each dressing change referencing Policy 10.027 Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters.
With each PICC dressing change, the clinician will obtain upper arm circumference (approximately 5cm above exit site) and compare to baseline measurement. Physician will be notified of any significant findings in measurement as this may be indicative of a thrombus.
With each PICC dressing change, the clinician will measure the external length of catheter from the insertion site to the catheter hub. Physician will be notified of any significant findings in measurement as this may indicate migration of catheter.
Measurements will be documented within the medical record.
Beginning the week of 4/27/2025, the Executive Director and/or Patient Care Manager will conduct 2 chart audits weekly for patients with PICC lines to ensure that mid arm circumference and external catheter length are documented in the medical record.
This monitoring will be done for 12 weeks and until 100% compliance achieved x 4 consecutive weeks.
Initial Comments:
Based on the findings of an unannounced, onsite state re-licensure survey conducted April 1 through April 4, 2025, Commonwealth Home Health &; Hospice of Wilkes-Barre was found not to be in compliance with the following requirements of 28 PA Code, Part IV, Health Facilities, Subpart G. Chapter 601.
\~
Plan of Correction:
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 the review of agency policies/procedures, documentation, clinical records and observation, and based on interview with the Administrator (Employee #12), the agency failed to ensure patient-specific wound care instructions had been provided in writing to two (2) of four (4) patients for whom wound care was performed by agency nursing staff. (Patients #7 and #8)
Findings include:
On April 4, 2025 at approximately 2:37 PM, review of the agency policy titled "Coordination of Care, From Admit to Discharge" revealed the following under "Procedure":
7. Coordination of care with patient and caregivers:
Written instructions obtained from the plan of care will be provided to the patient and caregiver outlining...
c. Treatments to be administered by agency staff...
d. Pertinent instructions related to the patient's care and treatments that the agency will provide, specific to the patient's needs...
Patient #7: Between April 3, 2025 at approximately7:43 AM and April 4, 2025 at approximately 7:45 AM, review of the clinical record revealed skilled nursing (SN) is to perform the following wound care as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/15/2025 through 04/15/2025. Cleanse left second toe wound with normal saline solution, apply Allevyn (foam wound dressing) using clean technique, two (2) time a week.
During home visit conducted on 04/03/2025, the RN (Employee #5) performed the above referenced wound care. Review of the patient's admission folder/folder failed to reveal instructions regarding the above referenced wound care orders had been provided to the patient in writing.
Patient #8: Between April 3, 2025 at approximately 3:17 PM and April 4, 2025 at approximately 7:59 AM, review of the clinical record revealed SN is to perform the following wound care as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/28/2025 through 04/28/2025. Cleanse right outer ankle wound with normal saline solution, pat dry with gauze, with a sterile Q-Tip apply Santyl (wound treatment) directly into the wound, cover with dry sterile dressing and secure with tape daily.
During home visit conducted on 04/03/2025 at approximately 11:35 AM, the RN (Employee #6) performed the above referenced wound care. Review of the patient's admission folder/folder failed to reveal instructions regarding the above referenced wound care orders had been provided to the patient in writing.
During interview conducted on April 4, 2025 at approximately 2:58 PM, the Administrator confirmed there was no documentation which provided evidence patient-specific wound care instructions had been provided to the above identified patients in writing.
Plan of Correction:Patient specific wound care instructions provided to patient's # 7 and 8.
During a mandatory meeting to be held on 4/22/2025, the Executive Director (ED) will instruct all clinical staff on the process of coordination of interventions with the patient/caregiver with an emphasis on ensuring specific wound care instructions are provided to the patient/caregiver referencing Policy 2.1.017 Coordination of Care, From Admit to Discharge and the Patient Written Instructions and Legal Representative Notice of Rights Job Aid.
Written information obtained from the plan of care will be provided to the patient and caregiver outlining treatments to be administered by staff or contract workers, including therapy services and pertinent instructions related to the patient's care and treatments that the agency
will provide, specific to the patient's needs, to include wound care.
The patient will receive a copy of the Patient Written Instructions Report which includes the visit frequency/schedule, medications, and treatments via mail once the plan of care is approved.
On the admission visit, the clinician will inform the patient and caregiver that they will receive written patient instructions in the mail and instruct them to keep the instructions with the home folder for reference.
On each subsequent visit, the clinician will review the home folder to ensure the Patient Instructions Report is
maintained and up to date, and inform the patient and caregiver of any changes to the plan of care, and manually edit the Patient Instruction Report for any visit frequency, medication, and/or
treatment changes.
Beginning the week of 4/27/2025, the Executive Director and/or Patient Care Manager will conduct 2 home visits weekly to ensure that the patient/caregiver have been given written instructions on wound care instruction in the home.
This monitoring will be done for 12 weeks and until 100% compliance achieved x 4 consecutive weeks.
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 the review of agency policies/procedures and clinical records, and based on interview with a registered nurses (RN-Employee #11) and the Administrator (Employee #12) , the agency failed to ensure documentation was maintained in the clinical record which provided evidence peripherally inserted central catheter (PICC-intravenous) assessment was completed in accordance with agency policy/procedure for two (2) of two (2) patients for whom PICC line dressing changes were completed by agency RN's. (Patients #11 and #12)
Findings include:
On April 4, 2025 at approximately 11:45 AM, review of the agency policy titled "Dressing Change Procedure for Central Venous, Midline, and Peripheral Inserted Central Catheters" revealed the following under "Procedure":
8. Inspect catheter, catheter exit site, and...
c. Obtain upper arm circumference...
d. Measure external length of catheter...
16. Document the procedure in the patient's record
On April 4, 2025 at approximately 2:34 PM, review of the agency policy titled "Patient Assessment, Initial and Reassessment" revealed the following under "Procedure":
NOTE: It is acceptable to use a general skill nursing progress note instead of an age-specific progress note, when the nurse deems appropriate...
6. Patient status is reviewed on an ongoing basis...
Patient #11: On April 4, 2025 between the approximate times of 8:40 AM and 11:45 AM, review of the clinical record revealed skilled nursing (SN) is to perform weekly PICC line dressing changes and observe and assess the PICC site as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 03/19/2025 through 05/17/2025.
Review of SN visit note report documentation dated 03/24 and 03/31/2025 revealed the RN (Employee #11) changed the right upper arm PICC line dressing but there was no documentation in the clinical record which provided evidence the RN assessed the circumference of the right upper arm nor the external length of the PICC line on the aforementioned dates.
During interview conducted on April 4, 2025 at approximately 2:45 PM, the RN (Employee #11) reported PICC line assessment on the aforementioned dates included measurement of the right upper arm circumference and external PICC line length. RN reported the electronic SN note previously included an area to document the arm circumference and external PICC line length but said area is no longer available in the electronic SN visit note which resulted in the PICC line assessment findings not being documented on the electronic SN visit note report.
Patient #12: On April 4, 2025 at approximately 8:58 AM, review of the clinical record revealed SN is to perform weekly PICC line dressing changes and that patient goals include for patient to remain free of infusion device complications as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/02/2025 through 04/02/2025.
Review of the recertification visit note report dated 04/01/2025 revealed the RN (Employee # 5) changed the right upper arm PICC line dressing but there was no documentation in the clinical record which provided evidence the RN assessed the circumference of the right upper arm nor the external length of the PICC line.
During interview conducted on April 4, 2025 at approximately 2:58 PM, the Administrator confirmed a recent software upgrade resulted in the elimination of the area to document PICC line assessment findings for arm circumference and external line length and that the clinical records of the above identified patients failed to include documentation which provided evidence PICC line assessment was performed in accordance with agency policy/procedure on the aforementioned dates.
Plan of Correction:Patient # 11 has been discharged from home health services.
Patient # 12 midarm circumference and external catheter length assessed and documented on subsequent visits when Peripherally Inserted Central Catheter (PICC) dressing was changed.
During a mandatory meeting to be held on 4/22/2025, the Executive Director will instruct all clinical staff on the process of complete assessment of the PICC line with emphasis on obtaining midarm circumference and external catheter length with each dressing change referencing Policy 10.027 Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters.
With each PICC dressing change, the clinician will obtain upper arm circumference (approximately 5cm above exit site) and compare to baseline measurement. Physician will be notified of any significant findings in measurement as this may be indicative of a thrombus.
With each PICC dressing change, the clinician will measure the external length of catheter from the insertion site to the catheter hub. Physician will be notified of any significant findings in measurement as this may indicate migration of catheter.
Measurements will be documented within the medical record.
Beginning the week of 4/27/2025, the Executive Director and/or Patient Care Manager will conduct 2 chart audits weekly for patients with PICC lines to ensure that mid arm circumference and external catheter length are documented in the medical record.
This monitoring will be done for 12 weeks and until 100% compliance achieved x 4 consecutive weeks.
Initial Comments:Based on the findings of an unannounced, onsite state re-licensure survey conducted April 1 through April 4, 2025, Commonwealth Home Health &; Hospice of Wilkes-Barre was found to be in compliance with the requirements of 28 Pa. Code, Health and Safety, 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 conducted April 1 through April 4, 2025, Commonwealth Home Health &; Hospice of Wilkes-Barre was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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