Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey conducted 8/1/2023 through 8/4/2023, Conemaugh 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:
484.55(c)(5) ELEMENT
A review of all current medications
Name - Component - 00
A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
Observations:
Based on a review of agency policy and procedure, medical record review (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking and identify for two (2) of seventeen (17) patient (MR5 and MR13).
Findings Included:
Review of the agency policy was conducted on 8/4/2023 at approximately 12:48 PM, Policy "MONITORING MEDICATIONS...POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for mediation review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. One therapy discipline will hold the primary responsibility for medication reconciliation in therapy only episodes of care...The physician is contacted immediately if any discrepancies between agency information and patient medications are found. All clinicians will have immediate access to current drug books and/or current web-based programs. PROCEDURES: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. B. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments, and medical marijuana (in states where legalized)..."
MR5 review was conducted on 8/4/2023 at approximately 11:55 AM, a review of the plan of care listed the start of care 6/14/2023 for a current certification period starting 6/14/2023 and ending 8/12/2023. The primary diagnosis was traumatic subarachnoid hemorrhage without loss of consciousness, subsequent encounter. The agency "Client Medication Report" received on 8/2/2023 was compared to the facilities "MAR" date printed 8/2/2023.
The following medication was not listed on the agency medication profile.
"MYRBETRIQ TAB 25 MG TAKE 1 TABLET ORALLY EVERY DAY...Date Written: 22-Jun-2023"
Review of MR13 was conducted on 8/2/2023 at approximately 12:25 PM, a review of the plan of care listed the start of care 6/23/2023 for a current certification period starting 6/23/2023 and ending 8/21/2023. The primary diagnosis was hypertensive heart disease with heart failure A secondary diagnosis of chronic obstructive pulmonary disease, unspecified was listed. The plan of care also listed under section "DME and Supplies: DME-OXYGEN SUPPLIES..." The agency "Client Medication Report" received on 8/1/2023 was review and oxygen was not listed. The surveyor requested for staff to confirm is oxygen was available for the patient. EMP2 confirmed oxygen supplies and equipment were in the patient's residence. The surveyor could not confirm oxygen use and/or equipment were part of the medication reconciliation.
An exit interview was conducted on 8/4/2023 at approximately 3:40 PM, (face to face) with the executive director, performance improvement coordinator clinical director. Joining via conference call was the divisional president, performance improvement staff and three branch office clinical directors which confirmed the above findings.
Plan of Correction:Physician was contacted and updated medication orders obtained on patient's MR5 and MR13.
Executive Director educated and provided copies of Monitoring Medications Policy 10.008 and education tools: Medication Reconciliation Job Aid and Patient Medication Review Questionnaire with emphasis on maintaining a current and accurate medication profile, and ensuring oxygen is included on the medication profile.
Discussion and education will be completed at a staff meeting with all staff on 8/29/23, 8/30/23, and 8/31/23.
Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician, and staff that includes all medications the patient is currently taking.
A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode.
For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager.
For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. One therapy discipline will hold the primary responsibility for medication reconciliation in therapy only episodes of care. When multiple therapy disciplines are being provided, the primary responsibility will be assigned as follows: Physical Therapy if ordered alone or in conjunction with other therapy disciplines; Occupational Therapy if ordered alone or in conjunction with only Speech Therapy; and Speech Therapy if only discipline providing care to patient. The therapist will collaborate with the Patient Care Manager to complete the process.
The physician is contacted immediately if any discrepancies between agency information and patient medications are found and the POC is updated as indicated.
Clinicians will utilize the Patient Medication Review Questionnaire to assist in identifying all medications the patient is currently taking.
Beginning 9/5/23, the Executive Director and/or trained designee will complete 20 observation visits (4 per branch) per month to ensure that the medication profile is complete and accurate for 3 consecutive months and until 100% compliant for 2 consecutive months.
484.70(a) STANDARD
Infection Prevention
Name - Component - 00
Standard: Infection Prevention.
The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.
Observations:
Based on review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for three (3) of seven (7) observations (OBV) providing direct care to patients (OBV3 MR3, OBV4 MR4 and OBV6 MR6).
Findings Included:
Review of the agency policy was conducted on 8/4/2023 at approximately 12:48 PM, Protocol "Home Care Bag Protocol Job Aid Field staff can use this job aid as a guide to home care bag use. The home care bag allows you to safely transport basic equipment and supplies necessary to perform a standard home visit...The contents of the home care bag is dictated by each disciplines' care requirements. Adherence to this protocol is mandatory. Discuss any questions regarding proper bag technique with your manager. HOME CARE BAG PROTOCOL...5. The home care bag will be stocked with the minimum necessary supplies to perform patient care for each specific discipline. It is the responsibility of the field staff to ensure that their bag remains sufficiently stocked...7. After entering the patient's home, place the bag on a clean, dry surface and a barrier placed between the bag and the surface. Avoid placing the bag on furniture or surfaces that are visible soiled/contaminated. Avoid soiled areas such as kitchen counters with soiled dishes and food items. Do not hang bag on doorknobs or backs of chairs..."
Visit (OBV3 MR3) on 8/3/2023 at approximately 10:25 AM patient care was conducted for (MR3) revealed, EMP6 provided direct patient care. EMP6 placed chucks/barriers on a coffee table with the healthcare bag on top of the chuck/barrier. The strap from the healthcare bag was laying off the chuck/barrier against the coffee table.
Visit (OBV4 MR4) on 8/3/2023 at approximately 11:28 AM patient care was conducted for (MR4) revealed, EMP7 provided direct patient care. EMP7 placed chucks/barriers on a dining table with the healthcare backpack on top of the chucks/barriers. Part of the straps from the healthcare backpack were laying off the edge of the barrier on to the tabletop.
Visit (OBV6 MR6) on 8/3/2023 at approximately 14:22 PM patient care was conducted for (MR6) revealed, EMP8 provided direct patient care. EMP8 placed chucks/barriers on the couch for healthcare bag supplies and equipment. After the initial interview/examination was conducted the patient. EMP8 moved to an additional room for dressing change to be completed. EMP8 pick up two of the chucks/barriers from the couch in the left hand then pick up a trash bag in the left hand and moved to the connecting room. The healthcare bag and equipment were placed on the two chucks/barriers.
An exit interview was conducted on 8/4/2023 at approximately 3:40 PM, (face to face) with the executive director, performance improvement coordinator clinical director. Joining via conference call was the divisional president, performance improvement staff and three branch office clinical directors which confirmed the above findings.
Plan of Correction:Employee 6, 7 and 8 completed skills lab demonstrating proper bag protocol and use of barriers.
Executive Director educated and provided copies of Home Care Bag Protocol Job Aid with emphasis on placing the bag on a clean, dry surface with a barrier placed between the bag and the surface and ensuring the bag, including the strap, remain on the barrier at all times.
Discussion and education completed at staff meeting with all staff on 8/29/23, 8/30/23, and 8/31/23.
Clinicians to enter the patient's home, place the bag on a clean, dry surface with a barrier placed between the bag and the surface.
Clinicians to obtain a clean barrier to place bag on when moving bag to a different area within the home.
Beginning 9/5/23, the Executive Director and/or trained designee will complete 20 observation visits (4 per branch) per month to ensure proper infection control for 3 consecutive months and until 100% compliant for 2 consecutive months.
Initial Comments:Based on the findings of an on-site unannounced Medicare recertification and state relicensure survey conducted 8/1/2023 through 8/4/2023, Conemaugh 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 on-site unannounced state relicensure survey completed 8/4/2023, Conemaugh Home Health was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on a review of the agency policy, CDC (Center for Disease Control) guidelines, personnel files (PF), and staff interview the agency failed to conduct testing in accordance with CDC guidelines related to communicable diseases for three (3) of five (5) PFs reviewed (PF3, PF4 and PF5). It was determined from review of agency policy, personnel files and staff (EMP) interview that the agency failed to obtain a federal criminal history record letter of determination for one (1) of five (5) PF reviewed (PF2).
Findings included:
Review of the agency policy was conducted on 8/4/2023 at approximately 1:52 PM, STAFF SCREENING, NEW HIRE AND ANNUAL...PURPOSE: To establish a process to ensure appropriate staff screening prior to hire and annually thereafter. POLICY: Upon hire to...Group or an affiliated organization (collectively referred to as "the Organization") each employee receives a conditional job offer pending the results of pre-employment drug screening. Current CDC recommendations direct that all U.S. health care personnel be screened for tuberculosis (TB) upon hire. All patient care staff or volunteers will be required to have Tuberculin Skin Test (TST), TB Blood Test (BAMT), tuberculin screen and/or chest X-ray, as deemed necessary, and based on the prevailing protocol used by the facility location..."
Review of CDC Guidelines on 8/9/2023 at approximately 8:51 AM revealed, "TB Screening and Testing of Health Care Personnel Updated August 30 2022 ...All U.S. health care personnel should be screened for TB upon hire (i.e., preplacement). The local health department should be notified immediately if TB disease is suspected. Annual TB testing of health care personnel is not recommended unless there is a known exposure or ongoing transmission ...CDC and the National TB Controllers Association released updated recommendations <https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s_cid=mm6819a3_w> for TB screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings <https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e>...
Baseline Testing: Two-Step Test If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used...Step 1Administer first TST following proper protocol Review result Positive -- consider TB infected, no second TST needed; evaluate for TB disease.* Negative -- a second TST is needed. Retest in 1 to 3 weeks after first TST result is read..."
PF#3, reviewed on 8/4/2023 at approximately 12:55 PM, date of hire 10/24/2022, revealed a TST screening that was administered on 10/24/2022 and read on 10/26/2022 with negative results. A second TST screening that was administered on 10/31/2022 and read on 11/2/2022 with negative results. The agency failed to administer the second TST test after a seven-day period (one week), from when the first TST result was read per CDC guidelines.
PF#4, reviewed on 8/4/2023 at approximately 1:08 PM, date of hire 4/4/2022, revealed a TST screening that was administered on 2/1/2022 and read on 2/3/2022 with negative results. A second TST screening that was administered on 2/7/2022 and read on 2/9/2022 with negative results. The agency failed to administer the second TST test after a seven-day period (one week), from when the first TST result was read per CDC guidelines.
PF#5, reviewed on 8/4/2023 at approximately 1:17 PM, date of hire 3/22/2021, revealed a TST screening that was administered on 3/22/2021 and read on 3/25/2021 with negative results. A second TST screening that was administered on 3/29/2021 and read on 4/1/2021 with negative results. The agency failed to administer the second TST test after a seven-day period (one week), from when the first TST result was read per CDC guidelines.
Findings included:
Review of the agency policy was conducted on 8/4/2023 at approximately 1:40 PM, BACKGROUND CHECKS...POLICY... All applicants who are offered employment with...Group must have a criminal background check successfully completed in order to remain with the company...Group follows the applicable state law for performing background and criminal history checks on all staff. PROCEDURE...19. In Pennsylvania, employees, volunteers, and contract workers: a. Must obtain the following clearances: a. Criminal history background check b. Child Abuse Clearance from the Department of Human Services (Child Abuse): and c. Fingerprint based federal criminal history check (FBI) if the applicant is not and for the two (2) years immediately preceding the date of application, has not been a Pennsylvania resident. b. Subject to the limited exception below, all applicable clearances must be obtained prior to employment and then again, every 60 months from the date of the oldest clearance. c. Agencies may employ applicants on a provisional basis not to exceed 30 days pending the results of a required FBI or Child Abuse check if all the following conditions are met: i. The applicant has completed the criminal history background check through...Group's criminal background check vendor; ii. The agency has no knowledge of information that would disqualify the applicant from employment; and iii. The applicant swears or affirms in writing that he or she is not disqualified from employment. d. Employees who have direct contact with a minor cannot start their job prior to the completion of a background check in its entirety. e. Agencies shall monitor any provisionally hired employee awaiting a criminal history check through random, direct observation and service recipient's feedback. The results of monitoring must be documented in the individual's employment file..."
Review of PF2, on 8/4/2023 at approximately 12:45 PM revealed, date of hire (DOH) 6/13/2022 A letter for processing an FBI clearance though the Pennsylvania Department of Human Resources was recorded on 6/9/2022. The document listed the following: "The above listed individual has completed the process of obtaining a fingerprint based record check. The individual's results were processed in accordance with the Child Protective Services law (Title 23 Pa C.S., Chapter 63). Results were mailed to the individual at the address they provided during registration. Please follow up with the individual regarding the results of their criminal record check..." No additional documentation was provided by the agency to confirm the results of the criminal record check were received and reviewed.
An exit interview was conducted on 8/4/2023 at approximately 3:40 PM, (face to face) with the executive director, performance improvement coordinator clinical director. Joining via conference call was the divisional president, performance improvement staff and three branch office clinical directors which confirmed the above findings.
Plan of Correction:Employees 3, 4, and 5 have completed the tuberculosis (TB) risk and screening using the Employee Tuberculosis Screening Form.
Employee 2 provided results of their criminal record check that was completed on 6/9/22.
HR files were reviewed for each employee to ensure a complete background check.
On 8/29/23, 8/30/23, and 8/31/23, the Executive Director will instruct the Business Manager (BM) on the TB screening process, with emphasis on the new hire TB screening and risk assessment, along with, the Background Check process, with emphasis on obtaining a copy of the results for the employee's personnel file.
All new staff will receive Tuberculosis (TB) screening on hire, to include a TB risk assessment, TB symptom screening, and TB test.
New hires to the provider having no history of a positive (reactive) response to the TST or BAMT are administered an initial preplacement TST or the BAMT and complete the TB Risk Assessment.
If a new hire has documentation of a negative TST administered within the last 12 months, the director or designee will ensure an initial TST is administered and document results on the Employee Tuberculosis Screening Form. The
previously documented test result, in conjunction with a pre- placement TST, will demonstrate compliance with the 2-step method as per CDC guidelines.
If a new hire has no documentation of a TST, or the documentation is greater than 12 months, the director or designee will ensure a second TST is administered within 1-3 weeks from the initial TST (2-step method). Both results are documented on the Employee Tuberculosis Screening Form.
All new staff will have a criminal background check completed upon hire, to include a fingerprint based federal criminal history check.
A copy of the background check results with be kept in the employee personnel file.
The BM will assure this has been completed prior to new staff providing patient care.
Beginning 9/5/23, the ED or designee will review 100% of new hire HR files from the previous month to ensure complete TB screening and criminal background checks with results has been completed prior to staff providing patient care.
Audits will be performed monthly for 3 months and until 100% compliance for 2 consecutive months.
Initial Comments:Based on the findings of an on-site unannounced State relicense survey completed 8/4/2023, Conemaugh Home Health 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 on-site unannounced State relicense survey completed 8/4/2023, Conemaugh Home Health was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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