Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey conducted February 26, 2024 through March 1, 2024, Holy Redeemer Home Care-Pa., 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(a) REQUIREMENT
ANNUAL POLICY REVIEW
Name - Component - 00
601.22(a) Annual Policy Review. A
group of professional personnel, which
includes at least one practicing
physician and one registered nurse,
and with appropriate representation
from other professional disciplines,
establishes and annually reviews the
agency's policies governing scope of
services offered, admission and
discharge policies, medical
supervision and plans of treatment,
emergency scope of services offered,
medical care, clinical records,
personnel qualifications, and program
evaluation.
Observations:
Based on review of agency documentation, review of policies, and an interview with the director of nursing, it was determined that agency failed to ensure a group of professional personnel, which includes at least one practicing physician and one registered nurse, and with appropriate representation from other professional disciplines, established and annually reviewed the agency's policies governing the scope of services offered.
Findings Include:
Review of agency policy was conducted on 3/1/24, at approximately 1:30 PM and revealed the following:
Policy 1-010 titled, "Professional Advisory Committee" stated, "The governing body will appoint a multidisciplinary Professional Advisory Committee (PAC). The committee will consist of at least one (1) practicing physician, a nurse with community health or home care experience, representatives of other professional services reflecting at least the scope of organization services (such as physical, speech or occupational therapy, and social work) and at least one (1) member that is neither an owner nor an employee of the organization..."
Review of meeting minutes on 3/1/24, at approximately 12:00PM revealed meetings of the Professional Advisory Committee on 10/20/21, 10/19/22 and 10/5/23. The Members present during the meeting on 10/20/21 did not include a practicing physician or social worker. The Members present during the meeting on 10/19/22 did not include a practicing physican. The Members present during the meeting on 10/5/23 did not include a social worker and social work is a service provided by the agency.
An interview with the Director of Nursing and Administrator on 3/1/24, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Education will be provided to the agency Administrator, Director of Clinical Operations, and Quality Staff regarding the requirement to maintain compliance with standard 601.22 (a): Annual Policy Review as detailed in agency policy 1-010 titled Professional Advisory Committee (PAC). Specifically, the agency will ensure that a group of professional personnel, which includes at least one practicing physician and one registered nurse, and with appropriate representation from other professional disciplines, establishes and annually reviews the agency's policies governing the scope of services offered.
Date of Compliance:
Education was provided to the agency Administrator and Director of Clinical Operations on 3/1/24.
Education was provided to Quality staff on 3/6/24.
Process to Prevent Recurrence:
Prior to the PAC meeting, the agency will ensure that the professional personnel roster for the PAC meeting includes at least one practicing physician and one registered nurse, with appropriate representation from other professional disciplines.
Quality staff will then audit PAC minutes in calendar 2024 to ensure that professional personnel in attendance include at least one practicing physician and one registered nurse, with appropriate representation from other professional disciplines.
Target threshold is 100%. Once 100% is met, Quality staff will continue to audit annually (for 2 years) to confirm sustainability.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on February 26, 2024 through March 1, 2024, Holy Redeemer Home Care-Pa, 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 onsite state re-licensure survey conducted on February 26, 2024 through March 1, 2024, Holy Redeemer Home Care-Pa, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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