Initial Comments:
Based on the findings of an onsite unannounced complaint survey conducted 12/8/23 and completed offsite 12/19/2023, Visiting Nurse Association Of Indiana County was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.50(d) STANDARD
Transfer and discharge
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Standard: Transfer and discharge.
The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if:
Observations:
Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide notify the patient of termination of services prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3).
Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide notify the patient of termination of services prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3).
Findings Included:
Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, "SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency. II. Procedure A. Discharge Planning begins with the admission visit. B. The discharge plan with effective date is developed cooperatively with the patient/patient representative. C. Clinical staff, in cooperation with the patient's physician, evaluates patient progress toward established goals and works together with the patient/patient representative for a timely discharge based on patient status. D. Discharge occurs in the following situations: 1. The patient reaches maximum rehabilitation and /or clinical status no longer requires skilled care...E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient's discharge from service. Agency Standards for Care require a Discharge Summary to be written for HomeHealth patients and sent to physician within the timeframe specified by Federal Regulations. F. The discharge Summary includes: *Date of admission and discharge *Physician responsible for the home health plan of care *Reason for admission to home health *Types of services provided and frequency of services *Medications the patient is on at time of discharge *Status of problems identified throughout the course of care, including, as appropriate, physical/psychosocial status, goals achieved, patient/family teaching, lab/vital signs parameters."
Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. MR3 was discharge from nursing services on 10/18/2023. No documentation was provided to confirm the patient was discharge from the agency. No documentation was provided to confirm the patient or patient representative was provided agency documents "Discharge Planning Guide, Discharge Instructions (or) Therapy Discharge Instructions," upon termination of services.
An interview was conducted with the executive director and quality assurance staff member on 12/8/2023 at approximately2:15 PM which confirmed the above findings.
Plan of Correction:How will the agency will correct the deficiency?
- The Agency contacted the patient on 12/9/23 to determine if home health services were needed. A new order was obtained from the physician and care resumed on 12/13/23. VNAIC continues to provide care for the patient in accordance with physician orders.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided to all discharging staff to review the agency's Discharge and Transfer Policies and steps to take for appropriate discharge planning and coordination of care.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audit all discharges from the Agency for the next 60 days to ensure proper discharge process is being followed per agency policy. Auditing to be completed by the Quality Assurance Nurse or designee and will begin 2/12/2024
484.50(d)(5)(iii) ELEMENT
Provide contact info other services
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(iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and
Observations:
Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide separation information to the patient prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3).
Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide separation information to the patient prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3).
Findings Included:
Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, "SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency. II. Procedure A. Discharge Planning begins with the admission visit. B. The discharge plan with effective date is developed cooperatively with the patient/patient representative. C. Clinical staff, in cooperation with the patient's physician, evaluates patient progress toward established goals and works together with the patient/patient representative for a timely discharge based on patient status. D. Discharge occurs in the following situations: 1. The patient reaches maximum rehabilitation and /or clinical status no longer requires skilled care...E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient's discharge from service. Agency Standards for Care require a Discharge Summary to be written for Home Health patients and sent to physician within the timeframe specified by Federal Regulations. F. The discharge Summary includes: *Date of admission and discharge *Physician responsible for the home health plan of care *Reason for admission to home health *Types of services provided and frequency of services *Medications the patient is on at time of discharge *Status of problems identified throughout the course of care, including, as appropriate, physical/psychosocial status, goals achieved, patient/family teaching, lab/vital signs parameters."
Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. MR3 was discharge from nursing services on 10/18/2023. No documentation was available to confirm the patient or patient representative was provided with information including contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient upon discharge.
An interview was conducted with the executive director and quality assurance staff member on 12/8/2023 at approximately2:15 PM which confirmed the above findings.
Plan of Correction:How will the agency will correct the deficiency?
- The Agency contacted the patient on 12/9/23 to determine if home health services were needed. A new order was obtained from the physician and care resumed on 12/13/23. VNAIC continues to provide care for the patient in accordance with physician orders.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided to all discharging staff to review the agency's Discharge and Transfer Policies and steps to take for appropriate discharge planning and coordination of care.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audit all discharges from the Agency for the next 60 days to ensure proper discharge process is being followed per agency policy. Auditing to be completed by the Quality Assurance Nurse or designee and will begin 2/12/2024
Initial Comments:
Based on the findings of an onsite unannounced complaint survey conducted 12/8/23 and completed offsite 12/19/2023, Visiting Nurse Association of Indiana County was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.36(a) REQUIREMENT
MAINTENANCE AND CONTENT OF RECORD
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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 review of agency policy, medical records (MR), and staff (EMP) interviews, the agency failed to ensure a discharged summary was submitted to the physician for one (1) of four (4) MR's reviewed (MR3).
Findings included:
Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, "SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency ...E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient's discharge from service. Agency Standards for Care require a Discharge Summary to be written for Home Health patients and sent to physician within the timeframe specified by Federal Regulations..."
Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. Per "Visit Note Report...10/18/2023...RN18-RN DISCHARGE FROM AGENCY...CARE COORDINATION, INDICATE IF YOU COMMUNICATED WITH OTHER INTERDICIPLINARY TEAM MEMBERS INVOLVED IN THIS CASE: YES, WHAT DISCIPLINE DID YOU COMMUNICATE WITH: PHYSICIAN...PROVIDE DETAILS OF COMMUNICATION WITH OTHER INTERDICIPLINARY TEAM MEMBERS: DC FROM AGENCY..." No written orders were submitted to the physician for signature per EMP1 for discharge from nursing services or agency discharge.
An interview was conducted with the executive director and quality assurance staff on 12/8/2023 at approximately2:15 PM which confirmed the above findings.
Plan of Correction:How will the agency will correct the deficiency?
- Event Report was submitted on 1/25/2024 under the "other" event type
Measures or systems the Agency will alter to ensure the problem does not occur:
- All clinical staff will be educated on the agency's Mandatory Event Reporting policy.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- A random sample of 5 charts per month will be reviewed until 100% compliance is met to ensure proper reporting to the DoH has been completed. Auditing to be completed by the Quality Assurance Nurse or designee and will begin 2/12/2024
Initial Comments:
Based on the findings of an onsite unannounced complaint survey conducted 12/8/23 and completed offisite 12/19/2023, Visiting Nurse Association Of Indiana County 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 (f) LICENSURE
NOTIFICATION
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51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on a review of the Event Reporting System (ERS), a review of agency documentation, medical records (MR) and staff (EMP) interview it was determined that the agency did not report services not rendered to the Department of Health related to consumers health and wellbeing for one (1) of four (4) MR reviewed (MR3).
Based on a review of the Event Reporting System (ERS), a review of agency documentation, medical records (MR) and staff (EMP) interview it was determined that the agency did not report patient services not rendered to the Department of Health related to consumers health and wellbeing for one (1) of four (4) MR reviewed (MR3).
Findings Included:
Review of the departments policy was conducted on 12/19/2023 between approximately 12:45 PM which revealed, "CHAPTER 51. GENERAL INFORMATION 51.3 Notification...
"(f) If a health care facility is aware of a situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing. The notification shall include sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation..."
Per interview with EMP3 on 12/19/2023 at approximately 1:09 PM the surveyor requested confirmation if an ERS report was submitted to the Department's Event Reporting System related to termination of services for MR3.
EMP1 confirmed on 12/19/2023 at approximately 2:34 PM that no report was submitted to the Department's Event Reporting System related to termination of services for MR3.
Plan of Correction:How will the agency correct the deficiency?
- Ensure that the agency is sending completed discharge summaries to all healthcare professionals who are listed in the patient record as responsible for providing care and services to the patient through education and monitoring.
- DC summary for MR3 was sent to all healthcare professionals (Durre Ahmeds) on 10/20/2023.
- Late entry DC Order was obtained 1/25/2024 and sent to Dr. Ahmeds for signature.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education to staff, including medical records and Team assistants, on the requirement and process of sending DC summaries to all physicians that are involved with the patient's care.
- Review of Discharge policy VII-4 with all clinical staff.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits of 5 Discharged charts/week to verify that physician was notified and the DC summaries were sent to all physicians involved with the patient's care timely, until 100% compliance. Then 10 charts per quarter will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation. Auditing to be completed by the Quality Assurance nurse or designee and will begin 2/12/2024
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