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 onsite unannounced Medicare recertification survey completed April 30, 2021, Clarion Forest VNA, Inc. 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(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 agency policy, clinical records (CR), observation during home visits (HV), and staff (EMP) interview, the agency failed to include all of the patient's medications on the plan of care for two (2) of two (2) home visits when the patient's medications and medication lists were reviewed (HV1, & HV2).

Findings included:

Review of agency policy on April 29, 2021, at approximately 2:00 p.m. showed:

"Policy Title: Medication Reconciliation... Visiting Nurse Association of America (VNAA) ... Interview the patient, family and caregiver to compile a comprehensive list of medications the patient takes, including over the counter (OTC) medications and document this in the patient's record."

"Content of Plan of Care ... PROCEDURE: The individual plan of care will include the following: ... All medications and treatments."

Review of CR6 on 4/28/2021 at approximately 12:35 p.m. showed a physician ordered plan of care beginning on 4/23/2021 for an initial certification period ending 6/21/2021. Per the plan, skilled nursing (SN) was to see the patient 1-2 times per week. Orders included, "Skilled services to complete a medication reconciliation of all medications to include and inventory for and assessment of availability of all medications the patient is taking, including new, changed and discontinued medications." SN last saw the patient on 4/26/2021.

Observation during HV1 with CR6 on April 28, 2021 at approximately 9:20 a.m. revealed the patient's most recent plan of care/medication list, printed on 4/27/2021, was not accurate and did not contain all of the medications the patient was taking. Interviews with the patient showed the following medications had been discontinued but still appeared as active on the patient's medication list: bumex and spironolactone. The patient stated, "I haven't taken those for weeks." It was also noted the patient was taking the following medications, but they did not appear on the patient's medication list: Equate Acetaminophen 650 milligrams (mg) two tablets at night for pain relief. Patient states "I've been taking that for a while." Observation of patient's medication bottles revealed the following dosing discrepancies: Allopurinol is to be taken as needed for gout, Amlodipine is not 10 mg the dose is 5mg, Tums are as needed, Carvedilol is 25mg not 12.5mg, Ferrous Sulfate is one tablet twice a day not every other day, Losartan is 50 mg not 100 mg. Interview with EMP1 and EMP2 on 4/30/2021 at approximately 11:30 a.m. confirmed that above findings.

Review of CR7 on 4/28/2021 at approximately 11:20 a.m. showed a physician ordered plan of care beginning on 4/2/2021 for an initial certification period ending 5/31/2021. Per the plan, skilled nursing (SN) was to see the patient 1-2 times per week. Orders included, "Skilled services to complete a medication reconciliation of all medications to include and inventory for and assessment of availability of all medications the patient is taking, including new, changed and discontinued medications." SN saw the patient on 4/5/2021, and 4/22/2021.

Observation during HV2 with CR7 April 28, 2021, at approximately 10:00 a.m. revealed the patient's most recent plan of care/medication list, printed on 4/27/2021, was not accurate and did not contain all of the medications the patient was taking. Omissions included:

Cranberry extract 500 mg taking one tablet daily; Probiotic OTC taking one tablet at night; Keflex 500 mg taking one tablet three times a day for 5 days - original prescription fill date of 4/23/2021.

Interview with EMP1 and EMP2 on 4/30/2021 at approximately 11:40 a.m. confirmed above findings.













Plan of Correction:

Action:
The CFVNA will conduct a competency on 5/18/21 & 5/20/21 for nursing and therapy staff. The VNAA policy on medication reconciliation will be reviewed. The staff will also watch a training video on medication reconciliation provided by the VNAA Blueprint Pathway to Best Practices on Medication Reconciliation. If upon the visit medication discrepencies (e.g.patient has missing medications/incorrect doses/physician notification on any issues) are noted the patient's next visit will occur within 24-72hours for reconciliation to be completed.
Monitoring: The Clinical Managers will be performing medication reconciliation with their yearly on-site performance evaluations starting on 6/10/21. Any employee who was evaluated prior to 6/10/21 will be evaluated again with an on-site visit by the clinical manager. The on-site evaluation form will be updated to reflect this. In addition, a patient sampling of 8 active patient records will be reviewed quarterly to assess for discrepencies comparing the medication record against the provided referral records. This review will be completed by the Nurse Educator. If discrepencies are found this will be reported to the clinical manager who will address this with the respective nurse. This review (of 8 patient record review quarterly) will continue until CFVNA staff is has met 100% compliance with reconciliation for the respective quarter.This review will start with the 2nd quarter of 2021.The Clinical Information Department will also monitor during OASIS review if discrepencies are documented and follow-up visits have not occurred in the above denoted time-frame. Again, the respective Clinical Manager will be alerted to any issues.


484.60(c)(1) ELEMENT
Promptly alert relevant physician of changes

Name - Component - 00
The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.

Observations:


Based on review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to promptly notify the physician to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered for three (3) of 18 records reviewed (CR1, CR2, & CR5).

Findings included:

Review of agency policy on April 30, 2021, at 11:10 a.m. showed:

"SCOPE OF SERVICES SKILLED NURSING ... The duties of the registered nurse included the following: ... 8. Informing physicians, staff, and team members of changes in patient condition and needs. ... The duties of the licensed practical nurse include the following: ... reporting to the registered nurse of the patient condition. ... SCOPE OF SERVICES PHYSICAL THERAPY ... 11. Contacts the physician for ... for any updates."

"CLARION FOREST VNA ... PHYSICIAN ORDERS ... Policy: ... The VNA will promptly alert relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and or that the plan of care should be altered. Examples included the following: (1) When the patient experiences a change either in his/her condition or response to treatment or medications."

Review of CR1 on April 27, 2021, at 11 a.m. showed a physician ordered plan of care beginning on 2/4/2020 for an initial certification period ending 4/3/202. Diagnosis was pneumonia, diabetes, lung disease, and pancreatic cancer. Skilled nursing was to see the patient for assessment such as weight gain of 3 lbs. (pounds) in 24 hours or 5 lbs. in 7 days, and "Communicate any significant changes to the patient's condition to physician." During the nursing start of care assessment completed on 2/4/2020, the patient's pain was rated at a 0 (numeric scale where 0 is no pain and 10 is maximal pain). On 2/10/2020, the patient's pain was a 4 (minimal pain). On 2/14/2020 subsequent nursing visit, the patient's pain was a 10. On 2/19/2020, the nurse documented the patient fell on 2/18/2020. On 2/20/2020, the PT (physical therapist) documented the patient had vomited and had a runny nose. On 2/21/2020, the RN documented the patient was nauseated and that the wife gave him a medication for it. On 2/25/2020, the nurse noted that yesterday (2/24/2020) patient's blood sugar had dropped to 51 which is below normal. On 2/25/2020, the PT documented the patient was not feeling well and had not eaten for the previous 3 days. The PT also noted the patient had a low blood sugar episode on 2/24/2020. Interviews with EMP1 and EMP2 on April 30, 2020, at 11:29 a.m. confirmed the above findings and that skilled professional did not notify the physician concerning the patient's fall, a change in pain from 4 to a 10, or the patient's nausea, lack of food intake and consequent low blood sugar.

Review of CR2 on April 27, 2021, at approximately 12:45 p.m. showed a physician ordered plan of care beginning on 11/25/2020 for initial certification period ending 1/11/2021. Diagnosis was acute on chronic systolic (congestive) heart failure, diabetes, chronic kidney disease, stage three unspecified. Skilled nursing was to see the patient for assessment such as initiate, monitor, reinforce and evaluate effectiveness of diabetic care and management, assess pain using standardized tool each visit and "Communicate any significant changes to the patient's condition to physician.". During the skilled nursing visit completed on 11/27/2020, the patient's pain was rated at a 0. On 11/30/2020, during the occupational therapy visit, the patient's pain was rated an 8 (severe) - no documentation of physician being notified. On 12/1/2020 during the skilled nursing visit the patient's pain was rated an 8 - no documentation of the physician being notified. Subsequent visits on 12/2/2020 pain level was rated at an 8, on 12/3/2020 pain level was rated 7, and on 12/4/2020 pain level was rated at a 7. No documentation that the physician was notified of the patient's pain levels. On 12/7/2020, occupational therapy documentation revealed that the patient had fallen on 12/6/2020 "she hit her cheek and arm" - no documentation of the physician being notified. On 12/7/2020, occupational therapy documented "blood sugar was 524 [above normal range]" which was an increase from the initial skilled nursing assessment on 11/25/2020 where blood sugar was noted to be 184 and reported blood sugar on 11/24/2020 was 53 - no documentation of physician being notified. Interviews with EMP1 and EMP2 on April 30, 2020, at approximately 11:40 a.m. confirmed the above findings and that skilled professional did not notify the physician concerning the patient's fall, a change in pain from 0 to an 8 or the patient's blood sugar result of 524.

Review of CR5 on April 27, 2021, at 1:15 p.m. showed a physician plan of care beginning on 7/3/2020 for a recertification period from 12/30/2020 to 2/27/2021. Orders included skilled nursing to see the patient for observation and assessment and, "Communicate any significant changes in the patient's condition to physician." On 1/15/2021, the registered nurse documented, "Notes: Pt has a large fluid filled blister to LLE [left lower extremity] anterior shin. Weeping serous fluid. Covered loosely with gauze 4x4 pads and wrapped with kling." The previous skilled nursing visit on 1/13/2021, did not show a fluid filled blister to patient's LLE. Interview with EMP1 and EMP2 on April 30, 2021, at 11:32 a.m. confirmed findings and no notification to patient's physician concerning new fluid filled blister.




Plan of Correction:

Action: CFVNA will conduct a competency on 5/18/21 and 5/20/21 to instruct therapy and nursing on promptly notifying physicians of relevant changes. Guidelines will be implemented by CFVNA to determine what is relevant including vital signs, bgms, uncontrolled pain, and s/s of disease processes to report to physicians. Nurses and therapists will be provided and instructed on this guidance at the above dated competency. Each case manager will be instructed on assigned monthly chart reivew of a co-worker's chart. The skilled chart review sheet will be updated to reflect CFVNA guidelines when to notify the physician of relevant changes. This review will be assigned starting 6/1/21.
Monitor: This will be monitored via chart reivew (each case manager and each therapist will be assigned 1 chart review per month to review a co-worker's patient record documentation/interventions). This will be tracked via a spreadsheet to be shared with the therapy/home health/palliative clinical managers. Chart review start/end dates will be for a 9 week certification period. If discrepencies are found the respective clinical manager will promptly notified and the employee will be counseled. This chart review will be on-going with no end-date.


484.75(b)(1) ELEMENT
Interdisciplinary assessment of the patient

Name - Component - 00
Ongoing interdisciplinary assessment of the patient;

Observations:


Based on review of agency policy, clinical records (CR), observation, and staff (EMP) interviews, skilled professional services failed to assume responsibility of the patient and conduct ongoing an assessment of the patient for 8 of 10 clinical records reviewed receiving physical therapy (PT) and/or occupational therapy (OT) service (CR1, CR2, CR3, CR5, CR7, CR9, CR12, & CR18). More to the point, PT and OT services developed plans of care and treated patients without completing a full assessment of the patient often times leaving the vital signs portion of the assessments blank or only with a partial assessment.

Findings included:

Review of CR1 on April 27, 2021, at 11 a.m. showed a physician ordered plan of care beginning on 2/4/2020 for an initial certification period ending 4/3/2020. Diagnoses were pneumonia, diabetes, lung disease, and pancreatic cancer. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. On 2/10/2020, PT and OT services were ordered and included evaluation and treatment, therapeutic exercises, gait training, and balance training 1-2 times per week. On 2/11/2020, the PT completed an initial evaluation (saw patient for the first time) of the patient but did not obtain a full set of vital signs (temperature, pulse, respirations, blood pressure). The PT only recorded the patient's pulse. On 2/12/2020, the OT completed an initial evaluation of the patient, but the OT did not record the patient's temperature or respirations. The PT and OT continued to treat the patient on the following days without a complete set of vital signs:

2/18/2020: PT visit with no vital signs. The "Vital Signs:" portion of the visit note was blank.
2/18/2020: OT visit with no vital signs.
2/20/2020: PT documented, "Pt reported being very fatigued following TE [therapeutic exercise] and gait training. No other exercises performed." The PT did not document any of the patient's vital signs.
2/21/2020: OT visit with no vital signs recorded.
2/25/2020: PT documented, "Pt reported not feeling well at all. Has not been able to eat for the past 4 days, limited on what he can do, ... he is just not able to do anything." The PT did not record any of the patient's vital signs.
2/25/2020: OT visit with no vital signs recorded.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:29 a.m. confirmed above findings.

Review of CR2 on April 27, 2021, at 12:45 p.m. showed a physician plan of care beginning on 11/25/2020 for an initial certification period from 11/25/2020 to 1/11/2021. Diagnoses included congestive heart failure, diabetes type 2, hypertension and chronic kidney disease stage 3. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT/OT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 11/30/2020, the OT performed an initial evaluation of the patient but the "vital signs" portion of the assessment was left blank. During subsequent OT visits on 12/3/2020, 12/7/2020 and 12/17/2020, the OT treated the patient but did not record vital signs. On 12/2/2020 the PT performed an initial evaluation of the patient but only recorded the patient's temperature. During subsequent PT visits on 12/4/2020, 12/8/2020, 12/10/2020, 12/14/2020 and 12/16/2020 the PT treated the patient but only recorded the patient's temperature.

Interview with EMP1 and EMP2 on April 30, 2021, at approximately 11:45 a.m. confirmed above findings.

Review of CR3 on April 27, 2021, at 10:45 a.m. showed a physician plan of care beginning on 4/10/2020 for an initial certification period from 4/10/2020 to 6/8/2020. Diagnoses included heart failure, type 2 diabetes and chronic kidney disease stage 3. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT/OT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 4/13/2020, the PT performed an initial evaluation of the patient but did not record the patient's blood pressure. During subsequent PT visits on 4/21/2020, 4/23/2020, 4/28/2020, 4/30/2020, and 5/7/2020, the PT treated the patient but only recorded the patient's temperature and heart rate. On 4/15/2020, the OT performed an initial evaluation of the patient but the "vital signs" portion of the assessment contained only temperature and oxygen level. During subsequent OT visits performed on 4/17/2020, 4/20/2020, 4/22/2020, 4/27/2020, 4/29/2020 and 5/4/2020 revealed temperature only obtained.
Interview with EMP1 and EMP2 on April 30, 2021, at 11:45 a.m. confirmed above findings

Note: PT made a visit for CR3 on 5/5/2020, and documented that he/she used telehealth vital signs taken at 8:16 a.m. - however, PT did not arrive onsite at residence until 8:56 a.m.

Review of CR5 on April 27, 2021, at 1:15 p.m. showed a physician plan of care beginning on 7/3/2020 for a recertification period from 12/30/2020 to 2/27/2021. Diagnoses included heart and lung disease. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 1/6/2021, the PT performed an initial evaluation of the patient but only recorded the patient's temperature. During subsequent PT visits on 1/12/2021 and 1/15/2021, the PT treated the patient but only recorded the patient's temperature.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:32 a.m. confirmed above findings.

Review of CR7 on April 28, 2021, at 11:25 a.m. showed a physician ordered plan of care beginning on 4/2/2021 for an initial certification period ending on 5/31/2021. Diagnoses included hypertensive chronic kidney disease, type 2 diabetes and hydrocephalus. The patient was taking several medications to treat her high blood pressure (can cause low blood pressure/dizziness). Orders included PT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 4/5/2021, the PT performed an initial evaluation of the patient and did not record vital signs. During subsequent PT visits on 4/7/2021 and 4/27/2021, the PT treated the patient and recorded only a temperature. On 4/8/2021, the OT performed an initial evaluation of the patient and did not record vital signs. During subsequent OT visits performed on 4/22/2021 and 4/26/2021 the OT treated the patient and the "vital signs" portion of the assessment had been left blank. During a home visit on 4/28/2021 at approximately 9:50 a.m. with the OT was observed at the patient's home, the OT was observed only recording the patient's temperature. When the OT requested the patient to stand from a sitting position the patient stated, "wait just a minute because I'm unsteady." The OT did not obtain vital signs during the home visit.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:45 a.m. confirmed above findings

Review of CR9 on April 29, 2021, at 12:45 p.m. showed a physician ordered plan of care beginning on 4/22/2021 for an initial certification period ending on 6/20/2021. Diagnoses included high blood pressure/heart disease and lung disease. The patient was taking several medications to treat her high blood pressure (can cause low blood pressure/dizziness). Orders included PT and OT evaluations and treatments for therapeutic exercise and functional mobility. The PT conducted an initial assessment of the patient on 4/26/2021 and only recorded the patient's temperature. The OT conducted an initial assessment of the patient on 4/26/2021 and only recorded the patient's temperature. During a home visit with the PT at the patient's home on 4/28/2021, the PT was observed only recording the patient's temperature. Interview with the PT (EMP6) after the visit at 1:04 p.m. confirmed he/she did not take a full set of vitals and asked why he/she did not he/she replied, "She has nursing in, we feel we don't need to check it each time."

Interviews with EMP1 and EMP2 on April 27, 2021, at 11:40 a.m. confirmed above findings.

Review of CR12 on April 29, 2021, at 1:30 p.m. revealed a physician ordered plan of care beginning on 4/21/2021 for an initial certification period ending 6/19/2021. Diagnoses included high blood pressure. Orders included PT/OT evaluations and treatments, therapeutic exercise, strengthening, gait training, and balance training. PT completed an initial evaluation of the patient on 4/22/2021 but only recorded the patient's temperature. OT completed an initial evaluation of the patient on 4/23/2021 and record none of the patient's vital signs. PT completed a subsequent visit on 4/26/2021 but only recorded the patient's temperature.

Interviews with EMP1 and EMP2 on April 27, 2021, at 11:42 a.m. confirmed above findings.

Review of CR18 on April 29, 2021, at 1:35 p.m. revealed a physician ordered plan of care beginning on 3/7/2021 for an initial certification period ending 5/5/2021. Diagnoses included left femur fracture, history of falls, hypertension (high blood pressure) and chronic kidney disease stage three. Orders included PT/OT evaluations and treatments, therapeutic exercise, strengthening, gait training, balance training, use of adaptive equipment and perform functional mobility for self care. On 3/9/2021 the PT completed an initial evaluation of the patient but did not obtain a full set of vital signs . On 3/9/2021, the OT completed an initial evaluation of the patient, but the OT did not record the patient's vital signs. Nursing services discharged on 3/25/2021 and became a therapies only case. The PT and OT continued to treat the patient on the following days without a complete set of vital signs:

3/11/2021: PT/OT visits with no vital signs.
3/16/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank.
3/17/2021: PT only documented the patient's temperature.
3/18/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/19/2021: PT only documented the patient's temperature.
3/23/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/24/2021: PT only documented the patient's temperature
3/25/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/26/2021: PT only documented the patient's temperature
4/1/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
and PT only documented the patient's temperature
4/5/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/6/2021: PT only documented the patient's temperature
4/7/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/13/2021: PT only documented the patient's temperature and OT visit with no vital signs. "Vital signs" portion of the note was blank
4/16/2021: PT only documented the patient's temperature and OT visit with no vital signs. "Vital signs" portion of the note was blank
4/19/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/20/2021: PT only documented the patient's temperature
4/21/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/23/2021: PT only documented the patient's temperature
4/27/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank

Interviews with EMP1 and EMP2 on April 30, 2021, at approximately 11:40 a.m. confirmed above findings.


2/18/2020: PT visit with no vital signs. The "Vital Signs:" portion of the visit note was blank.
2/18/2020: OT visit with no vital signs.
2/20/2020: PT documented, "Pt reported being very fatigued following TE [therapeutic exercise] and gait training. No other exercises performed." The PT did not document any of the patient's vital signs.
2/21/2020: OT visit with no vital signs recorded.
2/25/2020: PT documented, "Pt reported not feeling well at all. Has not been able to eat for the past 4 days, limited on what he can do, ... he is just not able to do anything." The PT did not record any of the patient's vital signs.
2/25/2020: OT visit with no vital signs recorded.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:29 a.m. confirmed above findings.

Review of CR2 on April 27, 2021, at 12:45 p.m. showed a physician plan of care beginning on 11/25/2020 for an initial certification period from 11/25/2020 to 1/11/2021. Diagnoses included congestive heart failure, diabetes type 2, hypertension and chronic kidney disease stage 3. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT/OT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 11/30/2020, the OT performed an initial evaluation of the patient but the "vital signs" portion of the assessment was left blank. During subsequent OT visits on 12/3/2020, 12/7/2020 and 12/17/2020, the OT treated the patient but did not record vital signs. On 12/2/2020 the PT performed an initial evaluation of the patient but only recorded the patient's temperature. During subsequent PT visits on 12/4/2020, 12/8/2020, 12/10/2020, 12/14/2020 and 12/16/2020 the PT treated the patient but only recorded the patient's temperature.

Interview with EMP1 and EMP2 on April 30, 2021, at approximately 11:45 a.m. confirmed above findings.

Review of CR3 on April 27, 2021, at 10:45 a.m. showed a physician plan of care beginning on 4/10/2020 for an initial certification period from 4/10/2020 to 6/8/2020. Diagnoses included heart failure, type 2 diabetes and chronic kidney disease stage 3. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT/OT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 4/13/2020, the PT performed an initial evaluation of the patient but did not record the patient's blood pressure. During subsequent PT visits on 4/21/2020, 4/23/2020, 4/28/2020, 4/30/2020, and 5/7/2020, the PT treated the patient but only recorded the patient's temperature and heart rate. On 4/15/2020, the OT performed an initial evaluation of the patient but the "vital signs" portion of the assessment contained only temperature and oxygen level. During subsequent OT visits performed on 4/17/2020, 4/20/2020, 4/22/2020, 4/27/2020, 4/29/2020 and 5/4/2020 revealed temperature only obtained.
Interview with EMP1 and EMP2 on April 30, 2021, at 11:45 a.m. confirmed above findings

Note: PT made a visit for CR3 on 5/5/2020, and documented that he/she used telehealth vital signs taken at 8:16 a.m. - however, PT did not arrive onsite at residence until 8:56 a.m.

Review of CR5 on April 27, 2021, at 1:15 p.m. showed a physician plan of care beginning on 7/3/2020 for a recertification period from 12/30/2020 to 2/27/2021. Diagnoses included heart and lung disease. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 1/6/2021, the PT performed an initial evaluation of the patient but only recorded the patient's temperature. During subsequent PT visits on 1/12/2021 and 1/15/2021, the PT treated the patient but only recorded the patient's temperature.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:32 a.m. confirmed above findings.

Review of CR7 on April 28, 2021, at 11:25 a.m. showed a physician ordered plan of care beginning on 4/2/2021 for an initial certification period ending on 5/31/2021. Diagnoses included hypertensive chronic kidney disease, type 2 diabetes and hydrocephalus. The patient was taking several medications to treat her high blood pressure (can cause low blood pressure/dizziness). Orders included PT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 4/5/2021, the PT performed an initial evaluation of the patient and did not record vital signs. During subsequent PT visits on 4/7/2021 and 4/27/2021, the PT treated the patient and recorded only a temperature. On 4/8/2021, the OT performed an initial evaluation of the patient and did not record vital signs. During subsequent OT visits performed on 4/22/2021 and 4/26/2021 the OT treated the patient and the "vital signs" portion of the assessment had been left blank. During a home visit on 4/28/2021 at approximately 9:50 a.m. with the OT was observed at the patient's home, the OT was observed only recording the patient's temperature. When the OT requested the patient to stand from a sitting position the patient stated, "wait just a minute because I'm unsteady." The OT did not obtain vital signs during the home visit.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:45 a.m. confirmed above findings

Review of CR9 on April 29, 2021, at 12:45 p.m. showed a physician ordered plan of care beginning on 4/22/2021 for an initial certification period ending on 6/20/2021. Diagnoses included high blood pressure/heart disease and lung disease. The patient was taking several medications to treat her high blood pressure (can cause low blood pressure/dizziness). Orders included PT and OT evaluations and treatments for therapeutic exercise and functional mobility. The PT conducted an initial assessment of the patient on 4/26/2021 and only recorded the patient's temperature. The OT conducted an initial assessment of the patient on 4/26/2021 and only recorded the patient's temperature. During a home visit with the PT at the patient's home on 4/28/2021, the PT was observed only recording the patient's temperature. Interview with the PT (EMP6) after the visit at 1:04 p.m. confirmed he/she did not take a full set of vitals and asked why he/she did not he/she replied, "She has nursing in, we feel we don't need to check it each time."

Interviews with EMP1 and EMP2 on April 27, 2021, at 11:40 a.m. confirmed above findings.

Review of CR12 on April 29, 2021, at 1:30 p.m. revealed a physician ordered plan of care beginning on 4/21/2021 for an initial certification period ending 6/19/2021. Diagnoses included high blood pressure. Orders included PT/OT evaluations and treatments, therapeutic exercise, strengthening, gait training, and balance training. PT completed an initial evaluation of the patient on 4/22/2021 but only recorded the patient's temperature. OT completed an initial evaluation of the patient on 4/23/2021 and record none of the patient's vital signs. PT completed a subsequent visit on 4/26/2021 but only recorded the patient's temperature.

Interviews with EMP1 and EMP2 on April 27, 2021, at 11:42 a.m. confirmed above findings.

Review of CR18 on April 29, 2021, at 1:35 p.m. revealed a physician ordered plan of care beginning on 3/7/2021 for an initial certification period ending 5/5/2021. Diagnoses included left femur fracture, history of falls, hypertension (high blood pressure) and chronic kidney disease stage three. Orders included PT/OT evaluations and treatments, therapeutic exercise, strengthening, gait training, balance training, use of adaptive equipment and perform functional mobility for self care. On 3/9/2021 the PT completed an initial evaluation of the patient but did not obtain a full set of vital signs . On 3/9/2021, the OT completed an initial evaluation of the patient, but the OT did not record the patient's vital signs. Nursing services discharged on 3/25/2021 and became a therapies only case. The PT and OT continued to treat the patient on the following days without a complete set of vital signs:

3/11/2021: PT/OT visits with no vital signs.
3/16/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank.
3/17/2021: PT only documented the patient's temperature.
3/18/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/19/2021: PT only documented the patient's temperature.
3/23/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/24/2021: PT only documented the patient's temperature
3/25/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/26/2021: PT only documented the patient's temperature
4/1/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
and PT only documented the patient's temperature
4/5/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/6/2021: PT only documented the patient's temperature
4/7/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/13/2021: PT only documented the patient's temperature and OT visit with no vital signs. "Vital signs" portion of the note was blank
4/16/2021: PT only documented the patient's temperature and OT visit with no vital signs. "Vital signs" portion of the note was blank
4/19/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/20/2021: PT only documented the patient's temperature
4/21/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/23/2021: PT only documented the patient's temperature
4/27/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank

Interviews with EMP1 and EMP2 on April 30, 2021, at approximately 11:40 a.m. confirmed above findings.








Plan of Correction:

Action: CFVNA will cunduct a separate competency for all therapy staff under the direction of the Nurse Educator on 5/20/21. Each therapist will demonstrate and be signed off on competency in completion of vital signs. CFVNA will also implement a policy and procedure denoting the requirements for complete of vital signs before and after each therapy visit. A memo of understanding will also be developed and signed by every therapist on 5/20/21 with the understanding on taking vital signs before and after therapy visits.

Monitor: Therapy visit notes will be reivewed for vital sign completion by the Therapy Clinical Manager. This will be initiated on 6/7/2021. This will be tracked via a google corrections spreadsheet. This wll be assessed for the 3rd quarter of 2021. Daily review of visit notes will cease once each therapist has achieved 100% compliance for the quarter.


484.105(f)(2)  ELEMENT
In accordance with current clinical practice

Name - Component - 00
All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice.

Observations:


Based on review of agency policy, observations during home visits (HV), and staff (EMP) interviews, the agency failed to ensure staff followed acceptable standards of practice for three (3) of four (4) observations of nursing bag technique (HV#1, HV#3, & HV#5).

Review of agency policy and procedure on April 30, 2021, at 10:47 a.m. showed:

"AGENCY PROGRAM: INFECTION CONTROL ... OVERVIEW ... Agency's [sic] must incorporate standards of infection control into every visit to reduce the risk of transmission of infections across patients and staff. Standards include: Hand hygiene; Environmental cleaning and disinfection; ... Appropriate use of personal protective equipment; reprocessing of reusable medical equipment between each patient. ... PROCEDURE ... 3. Always follow manufacturer's guidelines."

"HAND HYGIENE ... Hand hygiene using a waterless alcohol based antiseptic rub ... 1. dispense an ample amount of alcohol based product into the palm of one hand. 2. Rub the hands together and fingers with antiseptic rub ... Rub the palms of the hands together. ... 8. Rub the hands together until the alcohol is dry. Allow the hands to completely dry before donning gloves."

"STANDARD PRECAUTIONS ... OVERVIEW ... Always perform hand hygiene after removing gloves. ... PROCEDURE ... 4. Change gloves and perform hand hygiene during care as needed."

"IMPLANTED VENOUS PORT: ACCESS, DEACCESS, AND CARE ... PROCEDURE ... 17. Don a mask. Rationale: ... the infusion Nurses Society recommends that nurses wear a mask as additional protection when accessing an implanted port."

"MEDICAL EQUIPMENT: CLEANINIG AND DISINFECTING ... OVERVIEW ... When equipment is shared and not cleaned in between patient use, transmission of organisms can occur. ... EQUIPMENT ... Alcohol or disinfectant wipes ... Disinfectant agent per manufacturer's recommendations ... Noncritical equipment 1. Stethoscope: ... Blood pressure cuff: ... pulse oximeters: ... Wipe ... with an alcohol or disinfectant wipe after patient use. Let alcohol dry before placing into the nursing bag. Follow the manufacturer's specific recommendations for cleaning. Semicritical equipment 1. Thermometers: Wipe thermometers with an alcohol or antiseptic wipe."

"NURSING BAG TECHNIQUE ... Using the Bag ... If retrieving an item from the bag during the visit becomes necessary, perform hand hygiene first."

Observation of direct patient care during HV#1 with RN (EMP3) on April 28, 2021, at 8:58 a.m. revealed the nurse don gloves. The nurse then used alcohol based hand rub on gloved hands and removed equipment from supply bag. While wearing gloves, the nurse assisted the patient with her telehealth monitor and then obtained patient's vital signs using equipment such as stethoscope, blood pressure cuff, thermometer, and pulse oximeter. When the nurse was finished with his/her assessment he/she wiped equipment with hand sanitizing towelette then began placing the used equipment back into his/her nursing bag with gloved hands. Interview with EMP3 after the observation at 9:30 a.m. confirmed he/she used alcohol based hand rub on gloved hands, that hand sanitizing towelette used on equipment was for sanitizing hands, and that he/she placed items back into bag with gloved hands. Review of package for towelettes used on equipment during above observation with EMP3 showed, "Uses [sic] for hand sanitizing to decrease bacteria on the skin. Apply topically to the skin to help prevent cross contamination. Not recommended for repeated use. Dries in seconds." There was nothing on the package to show it was for the purpose of disinfecting health care items used on multiple patients.

Observation of direct patient care during HV#3 on April 28, 2021, at 10:35 a.m. revealed RN (EMP5) use equipment on patient to obtain vital signs. EMP5 then wiped items with hand sanitizing towelette (same as HV#1). EMP5 then used alcohol based hand rub on gloved hands and placed patient care equipment back inside nursing bag. EMP5 put a mask on his/her face and accessed patient's implanted venous port by inserting a needle into it and flushed with medications using a syringe, but EMP5's mask did not cover his/her nose. Interview with EMP5 at 11:05 a.m. confirmed findings. When asked why he/she was using alcohol based hand rub on his/her glove he/she noted, "It's what the hospitals do."

Observation of direct patient care during HV#5 on April 28, 2021, at 1:40 p.m. revealed LPN (EMP7) use equipment on patient to obtain his vital signs. Once completed, EMP7 placed alcohol based hand rub on gloved hands, opened nurse bag, removed a hand sanitizing towelette, and wiped patient care items with it. EMP7 then immediately placed items back into his/her nursing bag with gloved hands. Interview with EMP7 at time of observation confirmed above findings.














Plan of Correction:

Action: CFVNA will conduct a competency for nursing and therapy on 5/18/21 and 5/20/2021 on hand hygiene, bag technique, implanted port access/drsg change (nursing only), medical equipment cleaning and disinfection, and mask fitting and goggle fitting. Each nurse and therapist will demonstrate and be signed off as competent on the above noted procedures.Staff and the Facility Manager will be instructed on utilizing either 70% alcohol wipes or Microkill wipes to be used to disinfect medical equipment.
Monitor: This will be monitored by the clinical managers with on-site performance evaluations. This will commence on 6/1/2021 with evaluations. The on-site performane evaluations will be updated to reflet that the appropriate disinfectant solution was utilized during the on-site. In addition all staff will be instructed to bring their VNA bags in on by 5/21/21 allowing the clinical managers to inspect the disinfect product in the agency issued VNA bag to assure compliance.


Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey completed April 30, 2021, Clarion Forest VNA, Inc. 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 unannounced state license survey completed April 30, 2021, Clarion Forest VNA, Inc. 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:




601.31(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 agency policy, clinical records (CR), observation during home visits (HV), and staff (EMP) interview, the agency failed to include all of the patient's medications on the plan of care (treatment) for two (2) of two (2) home visits when the patient's medications and medications lists were reviewed (HV1, & HV2).

Findings included:

Review of agency policy on April 29, 2021, at approximately 2:00 p.m. showed:

"Policy Title: Medication Reconciliation... Visiting Nurse Association of America (VNAA)... Interview the patient, family and caregiver to compile a comprehensive list of medications the patient takes, including over the counter (OTC) medications and document this in the patient's record."

"Content of Plan of Care ... PROCEDURE: The individual plan of care will include the following: ... All medications and treatments."

Review of CR6 on 4/28/2021 at approximately 12:35 p.m. showed a physician ordered plan of care beginning on 4/23/2021 for an initial certification period ending 6/21/2021. Per the plan, skilled nursing (SN) was to see the patient 1-2 times per week. Orders included, "Skilled services to complete a medication reconciliation of all medications to include and inventory for and assessment of availability of all medications the patient is taking, including new, changed and discontinued medications." SN last saw the patient on 4/26/2021.

Observation during HV1 with CR6 on April 28, 2021 at approximately 9:20 a.m. revealed the patient's most recent plan of care/medication list, printed on 4/27/2021, was not accurate and did not contain all of the medications the patient was taking. Interviews with the patient showed the following medications had been discontinued but still appeared as active on the patient's medication list: bumex and spironolactone. The patient stated, "I haven't taken those for weeks." It was also noted the patient was taking the following medications, but they did not appear on the patient's medication list: Equate Acetaminophen 650 milligrams (mg) two tablets at night for pain relief. Patient states "I've been taking that for a while." Observation of patient's medication bottles revealed the following dosing discrepancies: Allopurinol is to be taken as needed for gout, Amlodipine is not 10 mg the dose is 5mg, Tums are as needed, Carvedilol is 25mg not 12.5mg, Ferrous Sulfate is one tablet twice a day not every other day, Losartan is 50 mg not 100 mg. Interview with EMP1 and EMP2 on 4/30/2021 at approximately 11:30 a.m. confirmed that above findings.

Review of CR7 on 4/28/2021 at approximately 11:20 a.m. showed a physician ordered plan of care beginning on 4/2/2021 for an initial certification period ending 5/31/2021. Per the plan, skilled nursing (SN) was to see the patient 1-2 times per week. Orders included, "Skilled services to complete a medication reconciliation of all medications to include and inventory for and assessment of availability of all medications the patient is taking, including new, changed and discontinued medications." SN saw the patient on 4/5/2021, and 4/22/2021.

Observation during HV2 with CR7 April 28, 2021, at approximately 10:00 a.m. revealed the patient's most recent plan of care/medication list, printed on 4/27/2021, was not accurate and did not contain all of the medications the patient was taking. Omissions included:

Cranberry extract 500 mg taking one tablet daily; Probiotic OTC taking one tablet at night; Keflex 500 mg taking one tablet three times a day for 5 days - original prescription fill date of 4/23/2021.

Interview with EMP1 and EMP2 on 4/30/2021 at approximately 11:40 a.m. confirmed above findings.







Plan of Correction:

Action: CFVNA clinical managers will perform an unannounced on-site visit (in addition to the yearly performance evaluation) with each nurse from June 1-June 11, 2021 to evaluate medication reconciliation on at least one current patient. Staff will be educated on 5/18 & 5/20/21 scheduled competencies on the CFVNA medication reconciliaiton p/p in addition to watching the mandated training presented by the VNAA Blueprint Pathways to Best Practices on Medication Reconciliation. The on-site performance evaluations will be updated to include medication reconcilation with the on-site evaluations.
Monitor: An unannounced on-site visit will be completed recurrently every month with the nurse by the clinical managers if there are issues denoted with the reconcilation during the initial encounter. This will continue until the clinical manager denotes 100% competency per the agency's policy & procedure on medication reconciliation. This will be tracked via a google spreadsheet including each nurse, date of on-site, medication reconciliation 100% competent or not competent, and the date of the follow-up visit if needed.


601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT

Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment

Observations:

Based on review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, professional staff failed to promptly alert the physician to any changes that suggest a need to alter the plan of care (treatment) for three (3) of 18 records reviewed (CR1, CR2, & CR5).

Findings included:

Review of agency policy on April 30, 2021, at 11:10 a.m. showed:

"SCOPE OF SERVICES SKILLED NURSING ... The duties of the registered nurse included the following: ... 8. Informing physicians, staff, and team members of changes in patient condition and needs. ... The duties of the licensed practical nurse include the following: ... reporting to the registered nurse of the patient condition. ... SCOPE OF SERVICES PHYSICAL THERAPY ... 11. Contacts the physician for ... for any updates."

"CLARION FOREST VNA ... PHYSICIAN ORDERS ... Policy: ... The VNA will promptly alert relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and or that the plan of care should be altered. Examples included the following: (1) When the patient experiences a change either in his/her condition or response to treatment or medications."

Review of CR1 on April 27, 2021, at 11 a.m. showed a physician ordered plan of care beginning on 2/4/2020 for an initial certification period ending 4/3/202. Diagnosis was pneumonia, diabetes, lung disease, and pancreatic cancer. Skilled nursing was to see the patient for assessment such as weight gain of 3 lbs. (pounds) in 24 hours or 5 lbs. in 7 days, and "Communicate any significant changes to the patient's condition to physician." During the nursing start of care assessment completed on 2/4/2020, the patient's pain was rated at a 0 (numeric scale where 0 is no pain and 10 is maximal pain). On 2/10/2020, the patient's pain was a 4 (minimal pain). On 2/14/2020 subsequent nursing visit, the patient's pain was a 10. On 2/19/2020, the nurse documented the patient fell on 2/18/2020. On 2/20/2020, the PT (physical therapist) documented the patient had vomited and had a runny nose. On 2/21/2020, the RN documented the patient was nauseated and that the wife gave him a medication for it. On 2/25/2020, the nurse noted that yesterday (2/24/2020) patient's blood sugar had dropped to 51 (normal fasting is 72-99 and patient was not eating). On 2/25/2020, the PT documented the patient was not feeling well and had not eaten for the previous 3 days. The PT also noted the patient had a low blood sugar episode on 2/24/2020. Interviews with EMP1 and EMP2 on April 30, 2020, at 11:29 a.m. confirmed the above findings and that skilled professional did not notify the physician concerning the patient's fall, a change in pain from 4 to a 10, or the patient's nausea, lack of food intake and consequent low blood sugar.

Review of CR2 on April 27, 2021, at approximately 12:45 p.m. showed a physician ordered plan of care beginning on 11/25/2020 for initial certification period ending 1/11/2021. Diagnosis was acute on chronic systolic (congestive) heart failure, diabetes, chronic kidney disease, stage three unspecified. Skilled nursing was to see the patient for assessment such as initiate, monitor, reinforce and evaluate effectiveness of diabetic care and management, assess pain using standardized tool each visit and "Communicate any significant changes to the patient's condition to physician.". During the skilled nursing visit completed on 11/27/2020, the patient's pain was rated at a 0. On 11/30/2020, during the occupational therapy visit, the patient's pain was rated an 8 (severe) - no documentation of physician being notified. On 12/1/2020 during the skilled nursing visit the patient's pain was rated an 8 - no documentation of the physician being notified. Subsequent visits on 12/2/2020 pain level was rated at an 8, on 12/3/2020 pain level was rated 7, and on 12/4/2020 pain level was rated at a 7. No documentation that the physician was notified of the patient's pain levels. On 12/7/2020, occupational therapy documentation revealed that the patient had fallen on 12/6/2020 "she hit her cheek and arm" - no documentation of the physician being notified. On 12/7/2020, occupational therapy documented "blood sugar was 524 [above normal range]" which was an increase from the initial skilled nursing assessment on 11/25/2020 where blood sugar was noted to be 184 and reported blood sugar on 11/24/2020 was 53 - no documentation of physician being notified. Interviews with EMP1 and EMP2 on April 30, 2020, at approximately 11:40 a.m. confirmed the above findings and that skilled professional did not notify the physician concerning the patient's fall, a change in pain from 0 to an 8 or the patient's blood sugar result of 524.

Review of CR5 on April 27, 2021, at 1:15 p.m. showed a physician plan of care beginning on 7/3/2020 for a recertification period from 12/30/2020 to 2/27/2021. Orders included skilled nursing to see the patient for observation and assessment and, "Communicate any significant changes in the patient's condition to physician." On 1/15/2021, the registered nurse documented, "Notes: Pt has a large fluid filled blister to LLE [left lower extremity] anterior shin. Weeping serous fluid. Covered loosely with gauze 4x4 pads and wrapped with kling." The previous skilled nursing visit on 1/13/2021, did not show a fluid filled blister to patient's LLE. Interview with EMP1 and EMP2 on April 30, 2021, at 11:32 a.m. confirmed findings and no notification to patient's physician concerning new fluid filled blister.









Plan of Correction:

Action: CFVNA will assign an RN case manager one skilled chart review per month to review a co-worker's patient to assess failure to alert the physician to any changes that could alter the plan of treatment. The CFVNA guidelines to determine what is relevant including vital signs, bgms, uncontrolled pain, and s/s of disease processes to report to physicians will be used as a guidance tool for the reviews. These reviews will begin on June 1, 2021 after all competencies are completed. Each case manager will be instructed on assigned monthly chart review of a co-worker's chart. The skilled chart review sheet will be updated to reflect CFVNA guidelines on when to notify the physician of relevant changes.
Monitor: The chart review will be an on-going process. Any issues found with chart review will be addressed with the clinical managers for intervention. This will be tracked via a spreadsheet to be shared with home health/palliative/therapy clinical managers. Chart review start/end dates will be a 9 week certification period. If discrepancies are found the respective clinical manager will be promptly notified and counseling will occur with the employee. This chart review will be on-going with no end date.


601.33(a) REQUIREMENT
QUALIFIED THERAPISTS

Name - Component - 00
601.33(a) Qualified Therapists. Any
therapy services offered by the agency
directly or under arrangement are
given by or under the supervision of a
qualified therapist in accordance with
the plan of treatment. The qualified
therapist:
(i) assists the physician in
evaluating level of function,
(ii) helps develop the plan of
treatment (revising as necessary),
(iii) prepares clinical and progress
notes,
(iv) advises and consults with the
family and other agency personnel, and
(v) participates in inservice
programs


Observations:


Based on review of clinical records (CR), observation, and staff (EMP) interviews, therapy services failed to assists the physician in evaluating level of function, and developing and revising the plan of care (treatment) for eight (8) of 10 clinical records reviewed receiving physical therapy (PT) and/or occupational therapy (OT) service (CR1, CR2, CR3, CR5, CR7, CR9, CR12, & CR18). More to the point, PT and OT services developed plans of care and treated patients without completing a full assessment of the patient often times leaving the vital signs portion of the assessments blank or only with a partial assessment. Therapy staff documented changes in the patient's condition, but failed to notify the physician concerning these findings. too much verbiage.... PT/OT failed to document complete assessments? Failed to notify physician of changes in patient condition? sounds like two citations? maybe I'm not understanding.....

Findings included:

Review of CR1 on April 27, 2021, at 11 a.m. showed a physician ordered plan of care beginning on 2/4/2020 for an initial certification period ending 4/3/2020. Diagnoses were pneumonia, diabetes, lung disease, and pancreatic cancer. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. On 2/10/2020, PT and OT services were ordered and included evaluation and treatment, therapeutic exercises, gait training, and balance training 1-2 times per week. On 2/11/2020, the PT completed an initial evaluation (saw patient for the first time) of the patient but did not obtain a full set of vital signs (temperature, pulse, respirations, blood pressure). The PT only recorded the patient's pulse. On 2/12/2020, the OT completed an initial evaluation of the patient, but the OT did not record the patient's temperature or respirations. The PT and OT continued to treat the patient on the following days without a complete set of vital signs:

2/18/2020: PT visit with no vital signs. The "Vital Signs:" portion of the visit note was blank.
2/18/2020: OT visit with no vital signs.
2/20/2020: PT documented, "Pt reported being very fatigued following TE [therapeutic exercise] and gait training. No other exercises performed." The PT did not document any of the patient's vital signs.
2/21/2020: OT visit with no vital signs recorded.
2/25/2020: PT documented, "Pt reported not feeling well at all. Has not been able to eat for the past 4 days, limited on what he can do, ... he is just not able to do anything." The PT did not record any of the patient's vital signs.
2/25/2020: OT visit with no vital signs recorded.

The PT and OT documented the following assessments without contacting the physician (MD) in order to assist the physician in evaluating or revising the plan of care:

Per the RN start of care from 2/4/2020, the patient's pain was rated at 0 (no pain).
On 2/12/2020, the OT documented the patient had pain rated at 8 (severe pain) with no MD notification.
On 2/20/2020, the PT documented the patient was vomiting and had a runny nose with no MD notification.
On 2/25/2020, the PT documented the patient was "not feeling well at all," had not eaten for 4 days, was "limited on what he [patient] could do," and had a low blood sugar episode on 2/24/2020 with no contact to the MD. Note: nursing also documented a low blood sugar of 51 (normal fasting range is 72-99 and patient was not eating), but also failed to notify the MD-- see Tag 1019 for more information.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:29 a.m. confirmed above findings.

Review of CR2 on April 27, 2021, at 12:45 p.m. showed a physician plan of care beginning on 11/25/2020 for an initial certification period from 11/25/2020 to 1/11/2021. Diagnoses included congestive heart failure, diabetes type 2, hypertension and chronic kidney disease stage 3. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT/OT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 11/30/2020, the OT performed an initial evaluation of the patient but the "vital signs" portion of the assessment was left blank. During subsequent OT visits on 12/3/2020, 12/7/2020 and 12/17/2020, the OT treated the patient but did not record vital signs. On 12/2/2020 the PT performed an initial evaluation of the patient but only recorded the patient's temperature. During subsequent PT visits on 12/4/2020, 12/8/2020, 12/10/2020, 12/14/2020 and 12/16/2020 the PT treated the patient but only recorded the patient's temperature. During the skilled nursing visit completed on 11/27/2020, the patient's pain was rated at a 0. On 11/30/2020, during the occupational therapy visit, the patient's pain was rated an 8 (severe) - no documentation of physician being notified. On 12/7/2020, occupational therapy documentation revealed that the patient had fallen on 12/6/2020 "she hit her cheek and arm" - no documentation of the physician being notified. On 12/7/2020, occupational therapy documented "blood sugar was 524 [above normal range]" which was an increase from the initial skilled nursing assessment on 11/25/2020 where blood sugar was noted to be 184 and reported blood sugar on 11/24/2020 was 53 - no documentation of physician being notified.

Interviews with EMP1 and EMP2 on April 30, 2020, at approximately 11:40 a.m. confirmed the above findings and that that the OT did not notify the physician concerning the patient's fall, a change in pain from 0 to an 8 or the patient's blood sugar result of 524.

Review of CR3 on April 27, 2021, at 10:45 a.m. showed a physician plan of care beginning on 4/10/2020 for an initial certification period from 4/10/2020 to 6/8/2020. Diagnoses included heart failure, type 2 diabetes and chronic kidney disease stage 3. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT/OT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 4/13/2020, the PT performed an initial evaluation of the patient but did not record the patient's blood pressure. During subsequent PT visits on 4/21/2020, 4/23/2020, 4/28/2020, 4/30/2020, and 5/7/2020, the PT treated the patient but only recorded the patient's temperature and heart rate. On 4/15/2020, the OT performed an initial evaluation of the patient but the "vital signs" portion of the assessment contained only temperature and oxygen level. During subsequent OT visits performed on 4/17/2020, 4/20/2020, 4/22/2020, 4/27/2020, 4/29/2020 and 5/4/2020 revealed temperature only obtained.
Interview with EMP1 and EMP2 on April 30, 2021, at 11:45 a.m. confirmed above findings

Note: PT made a visit for CR3 on 5/5/2020, and documented that he/she used telehealth vital signs taken at 8:16 a.m. - however, PT did not arrive onsite at residence until 8:56 a.m.

Review of CR5 on April 27, 2021, at 1:15 p.m. showed a physician plan of care beginning on 7/3/2020 for a recertification period from 12/30/2020 to 2/27/2021. Diagnoses included heart and lung disease. The patient was taking a multitude of medications to treat the aforementioned diagnoses some of which can cause low blood pressure or abnormal heart rate. Orders included PT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 1/6/2021, the PT performed an initial evaluation of the patient but only recorded the patient's temperature. During subsequent PT visits on 1/12/2021 and 1/15/2021, the PT treated the patient but only recorded the patient's temperature.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:32 a.m. confirmed above findings.

Review of CR7 on April 28, 2021, at 11:25 a.m. showed a physician ordered plan of care beginning on 4/2/2021 for an initial certification period ending on 5/31/2021. Diagnoses included hypertensive chronic kidney disease, type 2 diabetes and hydrocephalus. The patient was taking several medications to treat her high blood pressure (can cause low blood pressure/dizziness). Orders included PT evaluation and treatment, bed mobility, therapeutic exercises, gait training, and balance training 1-2 times per week. On 4/5/2021, the PT performed an initial evaluation of the patient and did not record vital signs. During subsequent PT visits on 4/7/2021 and 4/27/2021, the PT treated the patient and recorded only a temperature. On 4/8/2021, the OT performed an initial evaluation of the patient and did not record vital signs. During subsequent OT visits performed on 4/22/2021 and 4/26/2021 the OT treated the patient and the "vital signs" portion of the assessment had been left blank. During a home visit on 4/28/2021 at approximately 9:50 a.m. with the OT was observed at the patient's home, the OT was observed only recording the patient's temperature. When the OT requested the patient to stand from a sitting position the patient stated, "wait just a minute because I'm unsteady." The OT did not obtain vital signs during the home visit.

Interview with EMP1 and EMP2 on April 30, 2021, at 11:45 a.m. confirmed above findings

Review of CR9 on April 29, 2021, at 12:45 p.m. showed a physician ordered plan of care beginning on 4/22/2021 for an initial certification period ending on 6/20/2021. Diagnoses included high blood pressure/heart disease and lung disease. The patient was taking several medications to treat her high blood pressure (can cause low blood pressure/dizziness). Orders included PT and OT evaluations and treatments for therapeutic exercise and functional mobility. The PT conducted an initial assessment of the patient on 4/26/2021 and only recorded the patient's temperature. The OT conducted an initial assessment of the patient on 4/26/2021 and only recorded the patient's temperature. During a home visit with the PT at the patient's home on 4/28/2021, the PT was observed only recording the patient's temperature. Interview with the PT (EMP6) after the visit at 1:04 p.m. confirmed he/she did not take a full set of vitals and asked why he/she did not he/she replied, "She has nursing in, we feel we don't need to check it each time."

Interviews with EMP1 and EMP2 on April 27, 2021, at 11:40 a.m. confirmed above findings.

Review of CR12 on April 29, 2021, at 1:30 p.m. revealed a physician ordered plan of care beginning on 4/21/2021 for an initial certification period ending 6/19/2021. Diagnoses included high blood pressure. Orders included PT/OT evaluations and treatments, therapeutic exercise, strengthening, gait training, and balance training. PT completed an initial evaluation of the patient on 4/22/2021 but only recorded the patient's temperature. OT completed an initial evaluation of the patient on 4/23/2021 and record none of the patient's vital signs. PT completed a subsequent visit on 4/26/2021 but only recorded the patient's temperature.

Interviews with EMP1 and EMP2 on April 27, 2021, at 11:42 a.m. confirmed above findings.

Review of CR18 on April 29, 2021, at 1:35 p.m. revealed a physician ordered plan of care beginning on 3/7/2021 for an initial certification period ending 5/5/2021. Diagnoses included left femur fracture, history of falls, hypertension (high blood pressure) and chronic kidney disease stage three. Orders included PT/OT evaluations and treatments, therapeutic exercise, strengthening, gait training, balance training, use of adaptive equipment and perform functional mobility for self care. On 3/9/2021 the PT completed an initial evaluation of the patient but did not obtain a full set of vital signs . On 3/9/2021, the OT completed an initial evaluation of the patient, but the OT did not record the patient's vital signs. Nursing services discharged on 3/25/2021 and became a therapies only case. The PT and OT continued to treat the patient on the following days without a complete set of vital signs:

3/11/2021: PT/OT visits with no vital signs.
3/16/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank.
3/17/2021: PT only documented the patient's temperature.
3/18/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/19/2021: PT only documented the patient's temperature.
3/23/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/24/2021: PT only documented the patient's temperature
3/25/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
3/26/2021: PT only documented the patient's temperature
4/1/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
and PT only documented the patient's temperature
4/5/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/6/2021: PT only documented the patient's temperature
4/7/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/13/2021: PT only documented the patient's temperature and OT visit with no vital signs. "Vital signs" portion of the note was blank
4/16/2021: PT only documented the patient's temperature and OT visit with no vital signs. "Vital signs" portion of the note was blank
4/19/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/20/2021: PT only documented the patient's temperature
4/21/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank
4/23/2021: PT only documented the patient's temperature
4/27/2021: OT visit with no vital signs. "Vital signs" portion of the note was blank

Interviews with EMP1 and EMP2 on April 30, 2021, at approximately 11:40 a.m. confirmed above findings.


















Plan of Correction:

Action: CFVNA will assign a Therapy Case Manager one skilled chart review per month to review a co-worker's patient to assess failure to alert the physician(s) to any changes that could alter the plan fo treatment. The CFVNA established guidelines to determine what is relevant which includes vital signs, bgms, uncontrolled pain, and s/s of disease processes to report to physicians will be used as a guidance tool for the reviews. These reviews will begin June 1, 2021 after all competencies are completed. Each case manager will be instructed on assigned monthly chart review of a co-worker's chart. The skilled chart review sheet will be updated to reflect the CFVNA guidelines when to notify the physician of relevent changes.

Monitor: The chart review will be an on-going process. Any issues found with the reviews will be reported by the reviewer to the Therapy Manager for intervention. This will be tracked via a spreadsheet to be shared with the home health/palliative/therapy clinical managers. Chart review start/end dates will be for a 9 week certification period. If discrepanicies are found mangagers will be promptly notified and counseling will occur. This chart review will be on-going with no end date.


Initial Comments:

Based on the findings of an onsite unannounced state license survey completed April 30, 2021, Clarion Forest VNA, Inc. was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.







Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced state license survey completed April 30, 2021, Clarion Forest VNA, Inc. was found to be in compliance with the requirement of 35 P.S. 448.809 (b).




Plan of Correction: