QA Investigation Results

Pennsylvania Department of Health
CLARION FOREST VNA, INC.
Health Inspection Results
CLARION FOREST VNA, INC.
Health Inspection Results For:


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Initial Comments:Based on the findings of an unannounced onsite recertification and state re-licensure survey conducted April 9, 2024 through April 12, 2024 and offsite April 15, 2024, Clarion Forest VNA, Inc., 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 and state re-licensure survey conducted April 9, 2024 through April 12, 2024 and completed offisite April 15, 2024, Clarion Forest VNA, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:




484.60(a)(2)(i-xvi) ELEMENT
Plan of care must include the following

Name - Component - 00
The individualized plan of care must include the following:
(i) All pertinent diagnoses;
(ii) The patient's mental, psychosocial, and cognitive status;
(iii) The types of services, supplies, and equipment required;
(iv) The frequency and duration of visits to be made;
(v) Prognosis;
(vi) Rehabilitation potential;
(vii) Functional limitations;
(viii) Activities permitted;
(ix) Nutritional requirements;
(x) All medications and treatments;
(xi) Safety measures to protect against injury;
(xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
(xiii) Patient and caregiver education and training to facilitate timely discharge;
(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
(xv) Information related to any advanced directives; and
(xvi) Any additional items the HHA or physician or allowed practitioner may choose to include.

Observations:

Based on review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure the plan of treatment included complete orders for individualized plan of care required for two (2) of seventeen (17) CR reviewed (CR 13 and CR 14).

Findings included:



Review of agency policy on 4/10/2024 at approximately 1:30pm revealed:

"...Content of Plan of Care ...PROCEDURE: The individualized plan of care will included the following: ...The frequency and duration of visits to be made..."



Review of agency policy on 4/10/2024 at approximately 1:45pm revealed:
"... Physician Orders ...Policy: ... Physician orders must specify the treatment to be provided, the discipline(s) to provide frequency of visits."...
Review of Clinical Records (CR) on 4/10/2024 at revealed:



CR13, start of care (SOC) 3/16/2024, dates reviewed 3/15/2024-4/9/2024. Plan of Care (POC) included physician orders for "PT 1-2 x Week for 0 Weeks..." no duration ordered or documented.


CR14, SOC 3/1/2024, dates reviewed 3/1/2024 to 4/9/2024. included physician order "...Order Changes: Revision of Plan of Care: Add Home Health Aide services to assist patient with bathing 1-2x/week..." no duration ordered or documented.


Findings confirmed with administrator on April 10, 2024, at approximately 2:00pm. "I don't know how these orders got past us. I will have them corrected."








Plan of Correction:

The following steps will be taken to ensure the plan of treatment included complete orders for individualized plan of care required for two (2) of seventeen (17) CR reviewed (CR 13 and CR 14).
Mandated staff training will occur with all therapists and nurses on 4/30/24 & 5/1/24. The training will include instruction on Medicare Home Health Benefit Manual, Chapter 7, section, 30.2. 3, "specificity of orders",The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency and duration of the services. This training will be done by the CEO/CNO.
Every physician order with a verbal order will be reviewed and approved by the clinical managers prior to sending to physicians for signature. This will begin on 4/15/24. If any errors in physician orders are noted by the managers, the staff will be sent a correction by their clinical manager and educated on the error to be in compliance with the regulatory requirement on specificity of orders.



484.70(a) STANDARD
Infection Prevention

Name - Component - 00
Standard: Infection Prevention.
The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.

Observations: Based on review of manufactures directions for use, observations (OBS) with home visits (HV), review of agency policy and procedure, and an interview with the Administrator, the agency failed to ensure that acceptable standards of practice for infection control/prevention were maintained for four (4) of six (6) OBS (HV #3, #4, #5 and #6). Findings include: A review of the home health agency's (HHA) Policy and Procedure "Bag Technique ... Purpose: Prevent, reduce and control the spread of microorganisms... Bag Placement in the vehicle... The healthcare bag should be placed on a visibly clean, dry surface inside the vehicle... Bag Technique... Place the bag on a clean, dry surface with a water-resistant barrier placed between the bag and the surface... changed with every patient visit... Clean the equipment and supplies that had direct patient or environmental contact with agency approved disinfectant wipes and allow to dry..." Review of manufacturer's directions for use for disinfectant wipes "Micro-Kill One Germicidal Alcohol Wipes: ... Disinfecting: To disinfect hard, non-porous surfaces use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must be visibly wet for one (1) minute to achieve complete disinfection of all pathogens... allow surfaces to air dry... Contact Time: Allow surface to remain wet for one (1) full minute... Storage and Disposal: Always store this product and all pesticides in the original container..." 4/11/2024 approximately 10:00 am to 10:30 am - HV#3: State surveyor observed employee placing equipment bag, that was lined with clear plastic trash bags, directly on the patient's couch and placed the facility laptop without a barrier, directly on patient's couch. EMP completed patient care, did not remove the clear plastic trash bags from equipment bag, did not disinfect laptop and exited the patient's house with surveyor. Employee placed equipment bag, without removing clear plastic trash bags, directly on the employee's vehicle's backseat. Surveyor questioned employee regarding clear plastic trash bag removal... Employee stated, "I usually don't take it off of the bag prior to leaving the house." 4/11/2024 approximately 1:45pm to 2:30pm - HV#4: State surveyor observed employee performing disinfection of equipment with wipes that were removed from an unmarked, small clear plastic bag that was stored inside the equipment bag. Surveyor asked employee what the wipes were, and employee stated, "The Micro-Kill wipes but the container leaks if it tips over in my car, so I put new one's in this bag every day." 4/11/2024 approximately 12:00pm to 12:30pm - HV #5: State surveyor observed employee placing a single barrier onto a hard chair next to patient. The employee then removed "clean/unused" equipment directly from equipment bag, placing the equipment onto the barrier. The employee then used the "clean/unused" equipment to perform assessment on patient and returned the "dirty/used" equipment back onto the one and only barrier that the employee placed on the chair. Upon completion of assessment tasks with equipment, the employee proceeds to perform hand hygiene when assessment was complete and then immediately began to disinfect the "dirty/used" equipment with Micro-Kill One wipes. Immediately after wiping the "dirty/used" equipment the employee placed the disinfected, visibly wet equipment directly on the one and only "dirty/used" barrier that was in place on the chair. State surveyor asked employee if employee had more than one barrier in place to designate "clean" from "dirty" equipment and employee responds, "I do have more than one but did not put more than one out to separate "clean"/"disinfected" equipment from "dirty/used" barrier." 4/11/2024 approximately 12:45pm to 1:15pm - HV #6: State surveyor observed employee remove laptop from inside the equipment bag and place the laptop directly on patient cushioned top chair without a barrier. An interview conducted with the Administrator on 4/12/2024 at approximately 1:00 PM confirmed the above findings.

Plan of Correction:

The following steps will be taken to ensure 484.70(a) Standard Infection Prevention will be met:
CFVNA CEO/CNO will develop a step-by-step process to be followed for bag technique and computer disinfection technique. The process will be in compliance with current CDC standards on bag technique. All field staff will attend a mandated training to be presented by the CEO/CNO and instructed on this process. The trainings will occur on 4/30/24 & 5/1/24 Staff will watch a training video presented by the National Institute of Health on Bag Technique:
https://www.youtube.com/watch?v=Hhi-o5IgKDk
Staff will also demonstrate this process during the training.
All Clinical Managers will do on-site visits with staff within a 6 month timeframe to assess performance on computer and bag technique in the patient's home.



Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted April 9, 2024 through April 12, 2024 and offsite April 15, 2024, Clarion Forest VNA, Inc., 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:




601.31(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 on review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure the plan of treatment included complete orders for individualized plan of care required for two (2) of seventeen (17) CR reviewed (CR 13 and CR 14). Findings included: Review of agency policy on 4/10/2024 at approximately 1:30pm revealed: "...Content of Plan of Care ...PROCEDURE: The individualized plan of care will included the following: ...The frequency and duration of visits to be made..." Review of agency policy on 4/10/2024 at approximately 1:45pm revealed: "... Physician Orders ...Policy: ... Physician orders must specify the treatment to be provided, the discipline(s) to provide frequency of visits."... Review of Clinical Records (CR) on 4/10/2024 at revealed: CR13, start of care (SOC) 3/16/2024, dates reviewed 3/15/2024-4/9/2024. Plan of Care (POC) included physician orders for "PT 1-2 x Week for 0 Weeks..." no duration ordered or documented. CR14, SOC 3/1/2024, dates reviewed 3/1/2024 to 4/9/2024. included physician order "...Order Changes: Revision of Plan of Care: Add Home Health Aide services to assist patient with bathing 1-2x/week..." no duration ordered or documented. Findings confirmed with administrator on April 10, 2024, at approximately 2:00pm. "I don't know how these orders got past us. I will have them corrected."

Plan of Correction:

The following measures will occur to ensure 601.31(b)-plan of treatment regulatory requirement is met.
All verbal order physician orders will be checked and approved by clinical managers prior to sending to physicians for signature.
Coders will verify visit frequency comparing SOC/ROC/RCV reports to 485
Patient Schedulers will monitor visit frequency accuracy comparing ordered visit schedules to visits made. Patient schedulers will continue with chart review monitoring. Scheduler will report discrepancies to clinical managers. This will all begin on 4/15/24.



Initial Comments:Based on the findings of an unannounced onsite recertification and state re-licensure survey conducted on April 9, 2024 through April 12, 2024 and offsite April 15, 2024, Clarion Forest VNA, Inc., 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 on April 9, 2024 through April 12, 2024 and offsite April 15, 2024, Clarion Forest VNA, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction: