Initial Comments:
Based on the findings of an unannounced on-site federal recertification survey completed June 15, 2023, AccentCare Health of Pennsylvania 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 federal recertification survey completed June 15, 2023, AccentCare Health of Pennsylvania 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:
484.110(a)(6)(i-iii) ELEMENT
Discharge and transfer summaries
Name - Component - 00
(i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or
(ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or
(iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer.
Observations:
Based on a review of agency policy, review of clinical records, and an interview with the agency Clinical Manager, agency failed to send a completed transfer summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient when the patient's care was immediately continued in a health care facility for two (2) of five (5) transfer/discharge patient clinical records (CR) reviewed (CR#13, CR#14).
Findings include:
Agency policy reviewed on June 15, 2023 at approximately 1:30 p.m. Policy Number HH 2.1.7 'Home Health/Home Care' 'Patient Transfer and Discharge/NOMNC Notice' 'Procedure' (6) "A completed transfer summary is sent within (2) business days of a planned transfer if the patients care will be immediately continued in a health care facility or within (2) business days of the agency becoming aware of an unplanned transfer if the patient is still receiving care in a health care facility at the time when the agency becomes aware of the transfer."
A review of CRs was conducted on June 15, 2023 between approximately 10:00 a.m. and 1:30 p.m. The patients start of care (SOC) is listed below:
CR#13 SOC 02/02/23: Patient transferred to (hospital) on 02/23/23. The transfer summary was sent to the facility on 02/28/23. (3 business days after transfer). (Note: Agency paperwork states 02/22/23 as the agency discharge date. This date conflicts with the patient transfer date. Per the agency Clinical Manager on 06/15/23 at approximately 2:00 p.m., the agency identifies the patient discharge date as the last paid visit date.)
CR#14 SOC 03/04/23: Patient transferred to (hospital) on 04/27/23. The transfer summary was sent to the facility on 05/02/23. (3 business days after transfer). (Note: Agency paperwork states 04/12/23 as the agency discharge date. This date conflicts with the patient transfer date. Per the agency Clinical Manager on 06/15/23 at approximately 2:00 p.m., the agency identifies the patient discharge date as the last paid visit date.)
An interview conducted with agency Clinical Manager on June 15, 2023 at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:1. Starting on 6/27/23, the Administrator or Clinical Manager will ensure education is provided to all Patient Care Manager, Clinical Support Specialist, Registered Nurses, Licensed Practical Nurses, Therapists, and Social Workers and will include the following topics:
-Policy HH 2..1.7 Home Health/Home Care Patient Transfer and Discharge/NOMNC Notice
-My Patient my Responsibility
2. Starting on 7/3/23 the Administrator or Clinical Manager will review 25% of patients who are transferred to a facility weekly to ensure compliance with 484.110(a)(6)(i-iii) Discharge and transfer summaries. Audit will be shared with Regional leadership team on a weekly basis. Any gaps or compliance less than 100% will result in ongoing auditing.
3. Following the above stated audit, this indicator will become a regular part of the quarterly audit process for the Quality Assurance Performance Improvement (QAPI) Program. Audit results to be tracked, trended, shared with agency leadership, and reported to the QAPI committee on a quarterly basis. After the audit threshold is, achieved compliance will be monitored through the quarterly QAPI Clinical Record review and reported to PAC for review and recommendations.
Initial Comments:
Based on the findings of an unannounced on-site state licensure survey completed June 15, 2023, AccentCare Health of Pennsylvania 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
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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, review of clinical records, and an interview with the agency Clinical Manager, the agency failed to ensure a written summary report for each patient was sent to the attending physician at least every 60 days for five (5) of five (5) recertification clinical records (CR) reviewed (CR#8, CR#11, CR#12, CR#15, CR#16).
Findings Include:
Agency policy for sending the physician a written summary report at least every (60) days requested on June 15, 2023 at approximately 1:30 p.m. No specific policy provided.
A review of CRs was conducted on June 15, 2023 between approximately 10:00 a.m. and 1:30 p.m. The patients start of care (SOC) is listed below:
CR#8 SOC 03/02/23: Patients certification of the Plan of Care for the period of 03/02/23 - 04/30/23 reviewed. Patients current recertification period is 05/01/23-06/29/23. Documentation provided of a written summary of the certification period 03/02/23 - 04/30/23 being sent to the physician on 05/04/23 (64 days).
CR#11 SOC 03/30/23: Patients certification of the Plan of Care for the period of 03/30/23-05/28/23 reviewed. Patients current recertification period 05/29/23-07/27/23. Documentation provided of a written summary of the certification period 03/30/23-05/28/23 being sent to the physician on 06/01/23 (64 days).
CR#12 SOC 03/24/23: Patients certification of the Plan of Care for the period of 03/24/23-05/22/23 reviewed. Patients current recertification period is 05/23/23-07/21/23. Documentation provided of a written summary of the certification period 03/24/23-05/22/23 being sent to the physician on 05/26/23 (64 days).
CR#15 SOC 09/30/22: Patients certification of the Plan of Care for the period of 09/30/23-11/28/23 reviewed. Patients current recertification period 11/29/23-01/27/23. Documentation provided of a written summary of the certification period 09/30/23-11/28/23 being sent to the physician on 12/02/23 (64 days).
CR#16 SOC 01/19/23: Patients certification of the Plan of Care for the period of 01/19/23-03/19/23 reviewed. Patients current recertification period 03/20/23-05/18/23. Documentation provided of a written summary of the certification period 01/19/23-03/19/23 being sent to the physician on 03/23/23 (64 days).
An interview conducted with agency Clinical Manager on June 15, 2023 at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:1. Starting on 7/3/23 the Administrator or Clinical Manager will ensure that the End of Episode summary is sent to the Physician within the 5 day recertification window.
2. Starting on 7/3/23 the Administrator or Clinical Manager will review 15% Recertification's weekly to ensure an End of Episode summary was submitted. Audit will be shared with Regional leadership team on a weekly basis. Any gaps or compliance less than 100% will result in ongoing auditing.
3. Following the above stated audit, this indicator will become a regular part of the quarterly audit process for the Quality Assurance Performance Improvement (QAPI) Program. Audit results to be tracked, trended, shared with agency leadership, and reported to the QAPI committee on a quarterly basis. After the audit threshold is, achieved compliance will be monitored through the quarterly QAPI Clinical Record review and reported to PAC for review and recommendations.
601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS
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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, and an interview with the agency Clinical Manager, the agency failed to obtain a physician signature on verbal orders within seven (7) days on two (2) of seventeen (17) clinical records (CR) reviewed (CR#13, CR#17).
Findings include:
Agency policy reviewed on June 15, 2023 at approximately 1:30 p.m. Policy #HH 2.1.5 'Home Health/Home Care' 'Plan of Care' 'Pennsylvania' (d) Home Health care agency regulations ... (4) "Within 30 days of issuance, an order of home health care services must be signed and dated by a physician, nurse practitioner, or physician assistant."
28 Pa Code 601.31 'Acceptance of Patients, Plan of treatment and Medical Supervision' 'Overview' states "current Department regulations require physicians countersignature within 7 days of an oral order". 'Guideline' "Home Health Agency may vary from the 7 day requirement for countersignature of an oral order under the following conditions. 1. Accompanied by the agency's continuing efforts to obtain the countersignature within that time frame. If documentation of the attempts to obtain the required countersignature is provided, no deficiency citation will be issued". "Any oral 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 June 15, 2023 between approximately 10:00 a.m. and 1:30 p.m. The patients start of care (SOC) is listed below:
CR#13 SOC 02/02/23: Verbal physician's order taken by a registered nurse (RN) on 02/02/23. The physician's countersignature was obtained on 03/07/23 (34 days).
CR#17 SOC 12/02/22: Verbal physician's order taken by a registered nurse (RN) on 12/02/22. The physician's countersignature was obtained on 02/15/23 (76 days).
An interview conducted with agency Clinical Manager on June 15, 2023 at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:1. Starting on 6/27/23, the Administrator or Clinical Manager will ensure education is provided to all, Patient Care Manager, Clinical Support Specialist, Registered Nurses, Licensed Practical Nurses, Therapists, and Social Workers and will include the following topics:
-Policy HH 2.2.6 Physician Plan of Care
-HCHB job aide for verbal orders.
2. Starting on 7/3/23 the Administrator or Clinical Manager will review 15% of verbal orders weekly to ensure compliance with documentation and processes for receiving physician's orders signed in 7 days or 30 days per 28Pa Code 601.31. Audit will be shared with Regional leadership team on a weekly basis. Any gaps or compliance less than 100% will result in ongoing auditing.
3. Following the above stated audit, this indicator will become a regular part of the quarterly audit process for the Quality Assurance Performance Improvement (QAPI) Program. Audit results to be tracked, trended, shared with agency leadership, and reported to the QAPI committee on a quarterly basis. After the audit threshold is, achieved compliance will be monitored through the quarterly QAPI Clinical Record review and reported to PAC for review and recommendations.
Initial Comments:
Based on the findings of an unannounced on-site state licensure survey completed June 15, 2023, AccentCare Health of Pennsylvania 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 on-site state licensure survey completed June 15, 2023, AccentCare Health of Pennsylvania 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
Law amended July 11, 2022 Act 79 2022 HB 2604
(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.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(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) All other titles shall be determined by the
department. 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 on observation of Identification badges (ID) and an interview with the agency Clinical Manager, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on June 12, 2023 at approximately 1:00 p.m. revealed the current ID badge employee title does not occupy the bottom 1/2" of the badge, as large as possible. The employee photo is located next to the employee title, in the bottom left hand corner of the ID badge.
An interview conducted with agency Clinical Manager on June 15, 2023 at approximately 2:15 p.m. confirmed the above findings.
Plan of Correction:1. Starting on 6.27.23 Administrator or Clinical Manager will ensure education is provided to all Office Coordinators, Patient Care Managers, Clinical Support Specialist, Registered Nurses, Licensed Practical Nurses, Therapists, Social Workers and Home health aides that will include the following topics:
Photo ID badge regulation
2. Starting 6.27.23 Administrator or Clinical Manager will assign all Office Coordinators to begin replacing current employee identification badges to ensure:
-The photo identification tag shall include a recent photograph of the employee, employee's first name, employee's title, and name of home health agency.
-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 identification badge
-Titles shall not be abbreviated
3. Auditing will take place of every employees Photo ID badge beginning 7.10.23 by PCM during weekly case conferences. PCM will report weekly to Administrator or Clinical Manager the number of employees who have not had the ID badges corrected
4. Following the above stated audit onboarding of all new employees will consist of proper distribution of Photo ID Badge per H0010 35 P.S 448.809B Photo ID Reg
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