QA Investigation Results

Pennsylvania Department of Health
HOSPITAL HOME CARE SERVICES
Health Inspection Results

HOSPITAL HOME CARE SERVICES
Health Inspection Results For:

There are 12 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:Based on the findings of an onsite Medicare Recertification, State Licensure and Complaint Investigation Survey conducted 3/18/2024 through 3/22/2024, Hospital Home Care Services 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 onsite Medicare Recertification, State Licensure and Complaint Investigation Survey conducted 3/18/2024 through 3/22/2024, Hospital Home Care Services 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)(6) ELEMENT
Have a confidential clinical record
Name - Component - 00
Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164.

Observations:

Per the following Memorandums issued by the Pennsylvania DEPARTMENT OF STATE:
" April 13, 2020, Pennsylvania Changes Supervision Requirements for Physical Therapists, Occupational Therapists, Speech Language Pathologists and Audiologists During Covid-19 Emergency ... To increase patient and practitioner safety and decrease exposure to the virus, the Department of State requested, and the Governor approved, temporary suspension of all statutory and regulatory requirements for licensees ... that call for direct supervision, or require contact/interaction that is ' in-person, " " face-to-face, " " onsite, " " on the premises " or the like ... These temporary suspensions shall last for the duration of the COVID-19 emergency unless rescinded sooner or extended by the Governor or the Department. "

" May 4, 2022, COVID-19 REGULATORY SUSPENSIONS AND WAIVERS THAT WILL EXPIRE ON ... JUNE 20, 2022 ... Supervision Requirements for Physical Therapists ... This waiver suspended all statutory and regulatory requirements for licensees ... that call for direct supervision or require contact/interaction that is " in-person, " ' face-to-face, " " on-site, " " on the premises " or the like. "
Home Health Agency Conditions of Participation... January 2018 "The HIPAA Privacy Rule Sets national standards for covered entities (... health care providers that conduct certain health care transactions electronically)... including appropriate safeguards to protect the privacy of protected health information (PHI)... The Security Rule specifies safeguards that covered entities and their business associates must implement to protect the confidentiality, integrity, and availability of electronic protected health information (PHI)."
Based on review of Memorandums issued by the Pennsylvania DEPARTMENT OF STATE, Home Health Conditions of Participation, Clinical Records (CR) and staff (EMP) interviews, the agency provided Physical Therapy Services via Telehealth after the expiration date of June 20, 2022 for the temporary suspension of Home Health Services that "require contact/interaction that is " in-person, " ' face-to-face, " " on-site, " " on the premises " or the like " and did not provide appropriate safeguards to protect the privacy of protected health information (PHI), for two (2) of nine (9) CR of Patients who received Home Health Physical Therapy (CR1 &; CR2).
Findings included:
A Review of CR was conducted on 3/21/2022 from approximately 8:30 a.m. to 3:30 p.m.
Review of CR1, SOC 2/12/2024, on 3/18/2024 from approximately 10:00 a.m. to 11:00 a.m. revealed the following: " HOME HEALTH CERTIFICATION AND PLAN OF CARE ... Certification Period From: 2-12-2024 To: 4-11-2024 ... Principal Diagnosis Aftercare following joint replacement ... Orders for Discipline and Treatments ... Physical Therapy 2/12/24 - 2/16/2024 - 1 Within Five Days for 5 Days PHYSICAL THERAPY ASSISTANT: (Effective: 2/13/24) 02/14/24 - 02/24/24 - 2 Every Week for 1 Week; 3 Every Week for 1 Week. " The following Home Health Physical Therapy Admission Visit note revealed: " Start Date/Time: 02/12/24 02:30 End Date/Time:02/12/24 03:30 ... Clinician: (PF6) PT ... Visit Type HH PT Admit Visit ... Method: Who: Patient ... How: This evaluation was completed via synchronous telehealth visit with PTA as extender, with patient permission. Real time audio-video was utilized, and measures were taken to ensure patient privacy and adherence to HIPAA requirements. "
Review of CR2, SOC 2/14/2024, on 3/18/2024 from approximately 11:00 a.m. to 12:00 p.m. revealed the following: " HOME HEALTH CERTIFICATION AND PLAN OF CARE ... Certification Period From: 2-14-2024 To: 4-13-2024 ... Principal Diagnosis Aftercare following joint replacement ... Orders for Discipline and Treatments ... Physical Therapy 2/14/24 - 2/15/2024 - 1 Within Two Days for 2 Days PHYSICAL THERAPY ASSISTANT: 02/16/24 - 02/24/24 - 1 Every Week for 1 Week; 3 Every Week for 1 Week. " The following Home Health Physical Therapy Admission Visit note revealed: " Start Date/Time: 02/14/24 09:00 End Date/Time: 02/14/24 10:00 ... Clinician: (PF6) PT ... Visit Type HH PT Eval Visit ... Method: Who: Patient ... How: This evaluation was completed via synchronous telehealth visit with PTA as extender, with patient permission. Real time audio-video was utilized, and measures were taken to ensure patient privacy and adherence to HIPAA requirements. "
An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. confirmed the above findings. Surveyor Asked "What Real time audio-video was utilized for the telehealth visits?" Agency Administrator answered "Cell Phones". Surveyor asked "Were the cell phones utilized for telehealth owned by the Agency and issued to Clinicians for the specific purpose of conducting Agency business?" Agency Administrator Answered, "No, Clinicians utilize their own personal cell phones and are given a stipend as reimbursement for usage for Agency business," Surveyor then asked to see the "Cell Phone Policy," and the Agency Administrator replied, "We do not have one." When asked "What measures were taken to ensure patient privacy and adherence to HIPAA requirements?" Agency Clinical Manager answered "There is a HIPAA compliant app that is used for texting and written communication." Surveyor asked "How was the video portion of the telehealth visit protected?" Agency Clinical Director answered "I guess the video portion of the telehealth visit was not HIPAA compliant regarding privacy. A designated portal was not utilized for the transfer of video information between the PT and PTA."

Plan of Correction:

Hospital Home Care Services will discontinue the use of Telehealth Visits. The Director of Hospital Home Care Services notified the Clinical Manager and all staff on 4/4/2024 to discontinue Telehealth Visits to maintain compliance with the Home Health Agency Conditions of Participation.

Beginning the week of May 8, 2024 the Clinical Manager or a designee will conduct a chart audit of 5 PT/PTA visits per week to monitor telehealth visits. These audits will continue until there is a consecutive 4-week showing of 100% compliance. Random audits of four charts a month will then continue to ensure that the cited incidents will not recur.

484.60(c)(3)(ii) ELEMENT
Discharge plans communication
Name - Component - 00
(ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any).

Observations: Based on a review of clinical records (CR), and an interview with the agency staff, agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge for five (5) of five (5) discharged clinical records reviewed (CR1 - CR5). Findings included: A Review of CR was conducted on 3/21/2024 from approximately 8:30 a.m. to 3:30 p.m. Review of CR1, SOC 2/12/2024, certification period 2/12/2024 to 4/11/2024 revealed patient was discharged 2/23/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR2, SOC 2/14/2024, certification period 2/14/2024 to 4/13/2024 revealed patient was discharged 2/26/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR3, SOC 2/21/2024, certification period 2/21/2024 to 4/20/2024 revealed patient was discharged 2/30/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR4, SOC 2/08/2024, certification period 2/08/2024 to 4/07/2024 revealed patient was discharged 3/07/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR5, SOC 2/21/2024, certification period 2/21/2024 to 4/20/2024 revealed patient was discharged 2/26/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. confirmed the above findings.

Plan of Correction:

The Home Health Care Manager will have a staff meeting by April 22, 2024, to explain the importance of discharge plans communicated to the patient and also communication with the patient's primary care practitioner. Both of which will be noted in the patient's chart including the date and name of the patient's practitioner. In addition to correcting the discharge plans communication, the clinical manager will conduct a random chart audit for discharge patients for at least 4 weeks consecutively, showing 100% compliance with communication documented to the patient and also the primary care practitioner.

Education to the staff and monitoring of this deficiency until 100% compliance for at least 4 weeks by the clinical manager will ensure the problem has been addressed. Monthly chart audits by the clinical manager will be completed to hold staff accountable so that documented communication for discharge plans is compliant. These results will be shared with the hospital compliance officer, to ensure the finding continues to be addressed and monitored.

Initial Comments:Based on the findings of an onsite Medicare Recertification, State Licensure and Complaint Investigation Survey conducted 3/18/2024 through 3/22/2024, Hospital Home Care Services was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.

Plan of Correction:

601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS
Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.

Observations: Per the following Memorandums issued by the Pennsylvania DEPARTMENT OF STATE: " April 13, 2020, Pennsylvania Changes Supervision Requirements for Physical Therapists, Occupational Therapists, Speech Language Pathologists and Audiologists During Covid-19 Emergency ... To increase patient and practitioner safety and decrease exposure to the virus, the Department of State requested, and the Governor approved, temporary suspension of all statutory and regulatory requirements for licensees ... that call for direct supervision, or require contact/interaction that is ' in-person, " " face-to-face, " " onsite, " " on the premises " or the like ... These temporary suspensions shall last for the duration of the COVID-19 emergency unless rescinded sooner or extended by the Governor or the Department. " " May 4, 2022, COVID-19 REGULATORY SUSPENSIONS AND WAIVERS THAT WILL EXPIRE ON ... JUNE 20, 2022 ... Supervision Requirements for Physical Therapists ... This waiver suspended all statutory and regulatory requirements for licensees ... that call for direct supervision or require contact/interaction that is " in-person, " ' face-to-face, " " on-site, " " on the premises " or the like. " Based on review of Clinical Records (CR) and staff (EMP) interviews, the agency provided Physical Therapy Services via Telehealth after the expiration date of June 20, 2022 for the temporary suspension of Home Health Services that "require contact/interaction that is " in-person, " ' face-to-face, " " on-site, " " on the premises " or the like " for two (2) of nine (9) CR of Patients who received Home Health Physical Therapy (CR1 &; CR2). Findings included: A Review of CR was conducted on 3/21/2022 from approximately 8:30 a.m. to 3:30 p.m. Review of CR1, SOC 2/12/2024, on 3/18/2024 from approximately 10:00 a.m. to 11:00 a.m. revealed the following: " HOME HEALTH CERTIFICATION AND PLAN OF CARE ... Certification Period From: 2-12-2024 To: 4-11-2024 ... Principal Diagnosis Aftercare following joint replacement ... Orders for Discipline and Treatments ... Physical Therapy 2/12/24 - 2/16/2024 - 1 Within Five Days for 5 Days PHYSICAL THERAPY ASSISTANT: (Effective: 2/13/24) 02/14/24 - 02/24/24 - 2 Every Week for 1 Week; 3 Every Week for 1 Week. " The following Home Health Physical Therapy Admission Visit note revealed: " Start Date/Time: 02/12/24 02:30 End Date/Time:02/12/24 03:30 ... Clinician: (PF6) PT ... Visit Type HH PT Admit Visit ... Method: Who: Patient ... How: This evaluation was completed via synchronous telehealth visit with PTA as extender, with patient permission. Real time audio-video was utilized, and measures were taken to ensure patient privacy and adherence to HIPAA requirements. " Review of CR2, SOC 2/14/2024, on 3/18/2024 from approximately 11:00 a.m. to 12:00 p.m. revealed the following: " HOME HEALTH CERTIFICATION AND PLAN OF CARE ... Certification Period From: 2-14-2024 To: 4-13-2024 ... Principal Diagnosis Aftercare following joint replacement ... Orders for Discipline and Treatments ... Physical Therapy 2/14/24 - 2/15/2024 - 1 Within Two Days for 2 Days PHYSICAL THERAPY ASSISTANT: 02/16/24 - 02/24/24 - 1 Every Week for 1 Week; 3 Every Week for 1 Week. " The following Home Health Physical Therapy Admission Visit note revealed: " Start Date/Time: 02/14/24 09:00 End Date/Time: 02/14/24 10:00 ... Clinician: (PF6) PT ... Visit Type HH PT Eval Visit ... Method: Who: Patient ... How: This evaluation was completed via synchronous telehealth visit with PTA as extender, with patient permission. Real time audio-video was utilized, and measures were taken to ensure patient privacy and adherence to HIPAA requirements. " An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. confirmed the above findings.

Plan of Correction:

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 clinical records (CR), and an interview with the agency staff, agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge for five (5) of five (5) discharged clinical records reviewed (CR1 - CR5). Findings included: A Review of CR was conducted on 3/21/2024 from approximately 8:30 a.m. to 3:30 p.m. Review of CR1, SOC 2/12/2024, certification period 2/12/2024 to 4/11/2024 revealed patient was discharged 2/23/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR2, SOC 2/14/2024, certification period 2/14/2024 to 4/13/2024 revealed patient was discharged 2/26/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR3, SOC 2/21/2024, certification period 2/21/2024 to 4/20/2024 revealed patient was discharged 2/30/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR4, SOC 2/08/2024, certification period 2/08/2024 to 4/07/2024 revealed patient was discharged 3/07/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR5, SOC 2/21/2024, certification period 2/21/2024 to 4/20/2024 revealed patient was discharged 2/26/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. confirmed the above findings.

Plan of Correction:

Initial Comments:

Based on the findings of an onsite Medicare Recertification, State Licensure and Complaint Investigation Survey conducted 3/18/2024 through 3/22/2024, Hospital Home Care Services was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.

Plan of Correction:

51.3 (g)(1-14) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations: Based on a review of the agency's submission to the Department of Health's (DOH) online Event Reporting System (ERS), ERS Manual (Revised October 2016), a clinical record (CR) review, and staff (EMP) interview, the agency failed to notify the DOH of one (1) complaint of patient neglect, whether or not confirmed by the facility. Findings included: The agency's submissions to the DOH's online event reporting system and the ERS Manual (Revised October 2016) was reviewed on 3/15/2024 at approximately 8:00 a.m. There were no reports submitted by the Agency for the aforementioned reportable incident. The ERS Manual states on the "Event Reporting System- Facility Login...28 PA Code 51.3 Notification Confidential Information...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System is the mechanism the Department will use to meet this regulatory requirement." Review of CR1, SOC 2/12/2024, on 3/18/2024 from approximately 10:00 a.m. to 11:00 a.m. revealed an e-mail received by Agency Administrator on 2/13/2024 2:29 PM. "I am emailing you due to a concern I have... the PTA came... for... evaluation and called the PT on the phone to complete the evaluation... I do not believe that this is legal... the evaluation must be completed in person by the PT." An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. Confirmed the above findings. When asked why an ERS report was not filed by agency, Agency Administrator responded "She (Complainant) did not mention filing formally therefore, the hospital would not have placed it in the ERS system... our compliance officer was following up on a staff question regarding telehealth so she has no information to share."

Plan of Correction:

The facility entered the complaint from the patient into the event reporting system on 4/19/2024.

Our plan of correction for complaint notification to ensure this doesn't happen again will be to educate Home Health Care staff on the process to report an event and complaint online and also educate them on who our in-house complaint and grievance coordinator is and share their contact information with them. This will happen in a staff meeting on April 17, 2024. Staff will be required to sign off that they have been educated on our event report/complaint policy and procedures, to show they understand the importance of reporting all complaints.

To monitor that complaints are reported to the correct individual, monthly staff meetings, the clinical manager will remind all staff of the importance of reporting and elevating a complaint to the appropriate person, to ensure that the complaint is entered into the EFR system timely and addressed with the complainant.