QA Investigation Results

Pennsylvania Department of Health
AMEDISYS HOME HEALTH
Health Inspection Results
AMEDISYS HOME HEALTH
Health Inspection Results For:


There are  8 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an unannounced onsite Medicare recertification survey conducted March 11-12, 2020, Amedisys Home Health 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(b)(3)(4) ELEMENT
Verbal orders

Name - Component - 00
(3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies.

(4) When services are provided on the basis of a physician's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA's internal policies.

Observations:


Based on a review of agency policy, a review of clinical records (CRs), and an interview with the agency Administrator, agency failed to obtain the physician's counter-signature on oral orders within 7 days for two (2) out of eighteen (18) clinical records (CR#12, CR#18).

Findings Include:

Agency policy reviewed March 12, 2020 at approximately 11:00 a.m. Policy #TX-001 'Physician Orders and Medical Supervision of the Plan of Care' 'Medical Supervision' 'Days To Have Order(s) Signed by Physician Requirements per State' 'Pennsylvania' states "........... , shall .......and obtain physician counter signature within 7 days".

28 Pa. Code Acceptance of Patients, Plan of Treatment, and Medical Supervision (d) Conformance with Physicians Orders 'Guideline' states: "Home health agencies may vary from the 7 day requirement for countersignature of an oral order under the following conditions: An oral order not countersigned within 7 days must be accompanied by clearly documented evidence of the agency's continuing efforts to obtain the countersignature within that time frame". "Any order not countersigned within 30 days of original issue, regardless of the number of attempts to obtain countersignature, will result in a citation".

A review of CRs was conducted on March 12, 2020 between approximately 8:30 a.m. and 3:00 p.m. The patients start of care (SOC) is listed below:

CR#12 SOC 02/11/20: Patients Home Health Certification and Plan of Care certification period of 02/11/2020 - 04/10/2020 reviewed. A verbal physician's order for medication was entered/taken by a physical therapist (EF#13) on 02/25/2020 and approved/processed by a registered nurse (EF#3) on 02/27/2020. The physician's countersignature was obtained 03/10/2020 (15 days). No documented evidence of continuing efforts to obtain the countersignature.

CR#18 SOC 12/04/19: Patients Home Health Certification and Plan of Care certification period of 12/04/2019 - 02/01/2020 reviewed. A verbal physician's order for start of care was taken by a registered nurse (EF#12) on 12/04/2019. The physician's countersignature was obtained 01/23/2020 (51 days).
An interview conducted with agency Administrator on March 13, 2020 at approximately 3:30 p.m. confirmed the above findings.








Plan of Correction:

All Business Development/clinical staff to be re-educated on importance of obtaining correct physician for signature on all orders; to include first and last name of physician, fax # for office that patient is seen due to MD coverage in multiple offices and orders only to be signed in physical location serviced by 3/26/2020. All office staff to be inserviced on order tracking documentation by 3/26/2020. r/t601.31(d) conformance with physician orders. 25% of all verbal orders will be audited for countersignature effective start date of 3/26/20 for 30 days, 10% through 5/8/2020 with expected 100% compliance.


484.60(c)(1) ELEMENT
Reviewed, revised by physician every 60 days

Name - Component - 00
The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date.

Observations:


Based on a review of agency policy, a review of clinical records (CRs), and an interview with the agency Administrator, agency failed to have the total plan of treatment reviewed by the attending physician at least once every 60 days for two (2) out of three (3) clinical records with recertifications reviewed (CR#10, CR#20).


Findings Include:

Agency policy reviewed March 12, 2020 at approximately 11:00 a.m. Policy #TX-001 'Physician Orders and Medical Supervision of the Plan of Care' 'Medical Supervision' section (1) states "The total plan of care is reviewed and revised by the physician .........., but at least once every 60 days .......".

A review of CRs was conducted on March 12, 2020 between approximately 8:30 a.m. and 3:00 p.m. The patients start of care (SOC) is listed below:

CR#10 SOC 09/17/19: Patient's initial certification period was 09/17/2019-11/15/2019 (signed by physician on 10/14/2019). A recertification of the Plan of Care for the period of 11/16/2019-01/14/2020 (signed by physician on 12/24/2019). (72 days).

CR#20 SOC 09/20/19: Patient's initial certification period was 09/20/2019-11/18/2019 (signed by physician on 10/03/2019). A recertification of the Plan of Care for the period of 11/19/2019-01/17/2020 (signed by physician on 12/04/2019). (63 days).

An interview conducted with agency Administrator on March 13, 2020 at approximately 3:30 p.m. confirmed the above findings.







Plan of Correction:

Clinical manager to complete the recert/485 in HCHB in 5 day window as mandated. (day 55-59) Upon completion of task, the 485 to be printed by clinical manager with hand delivery to MD practice by Business Development within 24 hours. Order tracking report to be run to assess and audit compliance. 100 % of recerts to be audited 4/1-4/15, 50% 4/16-5/8 with expected 100% compliance. Inservice/training to all office staff and BD staff by 4/2/2020.


Initial Comments:


Based upon the findings of an unannounced onsite Medicare recertification survey conducted March 11-12, 2020, Amedisys Home Health 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 on-site home health agency state re-licensure survey conducted March 11-12, 2020, Amedisys Home Health 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:




601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES

Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.

Observations:


Based on a review of agency policy, and a review of clinical records (CRs), and an interview with the agency Administrator, agency failed to ensure a written summary report for each patient was sent to the attending physician at least every 60 days for three (3) of three (3) clinical records with recertifications reviewed (CR#10, CR#19, CR#20).

Findings Include:

Agency policy reviewed March 12, 2020 at approximately 11:00 a.m. Policy #TX-016 'Episode Summary Report' 'Pennsylvania' states "........ . A written summary report for each patient shall be sent to the attending physician at least every 60 days".

A review of CRs was conducted on March 12, 2020 between approximately 8:30 a.m. and 3:00 p.m. The patients start of care (SOC) is listed below:

CR#10 SOC 09/17/19: Patients certification of the Plan of Care for the period of 09/17/19-11/15/19. Documentation provided of a written summary being sent to the physician on 11/18/19 (63 days).

CR#19 SOC 11/04/19: Patients certification of the Plan of Care for the period of 11/04/19-01/02/20. Documentation provided of a written summary being sent to the physician on 01/07/20 (65 days).

CR#20 SOC 09/20/19: Patients certification of the Plan of Care for the period of 09/20/19-11/18/19. Documentation provided of a written summary being sent to the physician on 11/19/19 (61 days).

An interview conducted with agency Administrator on March 13, 2020 at approximately 3:30 p.m. confirmed the above findings.













Plan of Correction:

Educate CM/office staff to new process for compliance to 601.21(h) by 3/26/20. Clinical Manager upon completion of recert decision tasks in Home Care Home Base,(day 53-59) will fax episode summary report to physician for review of episode. If task not completed in HCHB, visit will not be generated in the workflow for clinician to perform recert skilled visit during 5 day recert period. Audit 100% of recerts 3/26-4/16, 50% of recerts 4/17-5/8 with expected 100% compliance.


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 a review of agency policy, a review of clinical records (CRs), and an interview with the agency Administrator, agency failed to have the total plan of treatment reviewed by the attending physician at least once every 60 days for two (2) out of three (3) clinical records with recertifications reviewed (CR#10, CR#20).


Findings Include:

Agency policy reviewed March 12, 2020 at approximately 11:00 a.m. Policy #TX-001 'Physician Orders and Medical Supervision of the Plan of Care' 'Medical Supervision' section (1) states "The total plan of care is reviewed and revised by the physician .........., but at least once every 60 days .......".

A review of CRs was conducted on March 12, 2020 between approximately 8:30 a.m. and 3:00 p.m. The patients start of care (SOC) is listed below:

CR#10 SOC 09/17/19: Patient's initial certification period was 09/17/2019-11/15/2019 (signed by physician on 10/14/2019). A recertification of the Plan of Care for the period of 11/16/2019-01/14/2020 (signed by physician on 12/24/2019). (72 days).

CR#20 SOC 09/20/19: Patient's initial certification period was 09/20/2019-11/18/2019 (signed by physician on 10/03/2019). A recertification of the Plan of Care for the period of 11/19/2019-01/17/2020 (signed by physician on 12/04/2019). (63 days).

An interview conducted with agency Administrator on March 13, 2020 at approximately 3:30 p.m. confirmed the above findings.






















Plan of Correction:

Clinical manager to complete the recert/485 in HCHB in 5 day window as mandated. (day 55-59) Upon completion of task, the 485 to be printed by clinical manager with hand delivery to MD practice by Business Development within 24 hours. Order tracking report to be run to assess and audit compliance. 100 % of recerts to be audited 4/1-4/15, 50% 4/16-5/8 with expected 100% compliance. Inservice/training to all office staff and BD staff by 4/2/2020.


601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS

Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.

Observations:


Based on a review of agency policy, a review of clinical records (CRs), and an interview with the agency Administrator, agency failed to obtain the physician's counter-signature on oral orders within 7 days for two (2) out of eighteen (18) clinical records (CR#12, CR#18).

Findings Include:

Agency policy reviewed March 12, 2020 at approximately 11:00 a.m. Policy #TX-001 'Physician Orders and Medical Supervision of the Plan of Care' 'Medical Supervision' 'Days To Have Order(s) Signed by Physician Requirements per State' 'Pennsylvania' states "........... , shall .......and obtain physician counter signature within 7 days".

28 Pa. Code Acceptance of Patients, Plan of Treatment, and Medical Supervision (d) Conformance with Physicians Orders 'Guideline' states: "Home health agencies may vary from the 7 day requirement for countersignature of an oral order under the following conditions: An oral order not countersigned within 7 days must be accompanied by clearly documented evidence of the agency's continuing efforts to obtain the countersignature within that time frame". "Any order not countersigned within 30 days of original issue, regardless of the number of attempts to obtain countersignature, will result in a citation".

A review of CRs was conducted on March 12, 2020 between approximately 8:30 a.m. and 3:00 p.m. The patients start of care (SOC) is listed below:

CR#12 SOC 02/11/20: Patients Home Health Certification and Plan of Care certification period of 02/11/2020 - 04/10/2020 reviewed. A verbal physician's order for medication was entered/taken by a physical therapist (EF#13) on 02/25/2020 and approved/processed by a registered nurse (EF#3) on 02/27/2020. The physician's countersignature was obtained 03/10/2020 (15 days). No documented evidence of continuing efforts to obtain the countersignature.

CR#18 SOC 12/04/19: Patients Home Health Certification and Plan of Care certification period of 12/04/2019 - 02/01/2020 reviewed. A verbal physician's order for start of care was taken by a registered nurse (EF#12) on 12/04/2019. The physician's countersignature was obtained 01/23/2020 (51 days).
An interview conducted with agency Administrator on March 13, 2020 at approximately 3:30 p.m. confirmed the above findings.





















Plan of Correction:

All Business Development/Clinical staff to be re-educated on importance of obtaining correct physician information to include; full name of physician, fax # for office that patient is seen due to physicians with multiple physical sites by 3/26/20. Physicians require that all orders must be processed at location patient seen. All office staff to be educated on order tracking documentation by 3/26/20. r/t601.31(d) 25% of all verbal orders will be audited for countersignature x 30 days, 10% through 5/8 with expected 100% compliance with plan in place. If 100% not achieved, 10% will be audited q month until 100% compliance achieved.


Initial Comments:


Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted March 11-12, 2020, Amedisys Home Health 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 relicensure survey conducted March 11-12, 2020, Amedisys Home Health was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:

Based upon observation of Identification badges (ID) and interview with the agency administrator, agency failed to format ID badges per regulatory requirements for one (1) of one (1) observation. (OBS #1).

Findings include:

(OBS#1): Observation of employee Identification Badge (ID) on March 12, 2020 at approximately 2:45 p.m., revealed the ID badge title of the employee was not as large as possible in block type and did not occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge. The one-half inch space at the bottom of the ID badge contained both the title of the employee and the location (city) of the agency.


An interview conducted with agency Administrator on March 13, 2020 at approximately 3:30 p.m. confirmed the above findings. Per the Administrator, "There are approximately fifty-two (52) agency ID badges are in this format".








Plan of Correction:

Amedisys Corporate will manually convert 100% of all Lancaster Care Center employee badges to comply with House Bill no 1482. 35.p.s.448.809b Badge to include recent photo, employee name, title, and name of employer.