Initial Comments:Based on the findings of an unannounced onsite Home Health Agency Medicare Recertification Survey conducted March 18, 2024 through March 20, 2024, Ken-Care Home Health Agency was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the findings of an unannounced onsite Home Health Agency Medicare Re-Certification Survey conducted March 18, 2024 through March 20, 2024, Ken-Care Home Health Agency 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:
484.65(d)(1)(2) STANDARD
Performance improvement projects
Name - Component - 00
Standard: Performance improvement projects.
Beginning July 13, 2018 HHAs must conduct performance improvement projects.
(1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations.
(2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.
Observations:
Based on a review of home health agency (HHA) documents and an interview with the Home Health Agency Director (Dir), the agency failed to provide evidence that at least one performance improvement project was conducted annually.
Findings include:
The quality assessment and improvement program and data for 2022 and 2023, reviewed March 19, 2024 at 12:00 PM, and again on March 20, 2024 at 10:00 AM did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023.
Governing Body Meeting Minutes, dated May 22, 2023 and May 22, 2022, reviewed March 19, 2024 at 1:00 PM and again on March 20, 2024 at 9:30 AM, did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023.
Annual Program Evaluation Reports, dated May 12, 2023 and May 12, 2022, reviewed on March 19, 2024 at 12:45 PM, did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023.
Professional Advisory Committee Meeting Minutes, dated March 6, 2023 and March 22, 2022, reviewed on March 19, 2024 at 12:30 PM, did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023.
An interview on March 19, 2024 at 12:30 PM and again on March 20, 2024 at 10:30 AM with the Dir revealed that the HHA had not identified and conducted any performance improvement projects in 2022 or 2023.
An interview with the Director and the Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.
Plan of Correction:By May 29, 2024 a performance improvement project will be identified, developed and conducted.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above.
Effective May 1, 2024 a Performance Improvement Project committee will be established to identify, develop and conduct the performance improvement plan. The committee will consist of the Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant.
The Performance Improvement Committee will meet monthly to review identified project and data.
The committee will report progress and data to the Administrator quarterly.
484.65(e)(1)(2)(3)(4) STANDARD
Executive responsibilities for QAPI
Name - Component - 00
Standard: Executive responsibilities.
The HHA's governing body is responsible for ensuring the following:
(1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained;
(2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness;
(3) That clear expectations for patient safety are established, implemented, and maintained; and
(4) That any findings of fraud or waste are appropriately addressed.
Observations:
Based on a review of governing board meeting minutes, the annual program evaluation, the professional advisory committee meeting minutes, clinical record review indicators, and an interview with the Director and Administrator, the agency did not demonstrate that the governing body addressed priorities for improved quality of care and patient safety, focused on indicators related to improved outcomes, ensured the effectiveness of the improvement efforts, and established clear expectations for the implementation and maintenance of patient safety.
Findings include:
Governing Body Meeting Minutes, dated May 22, 2023 and May 23, 2022, reviewed March 19, 2024 at 1:00 PM and again on March 20, 2024 at 9:30 AM, contained the same language each year as follows: "Be it further resolved that the Ken-Crest Services Board of Directors approves the program evaluation."
Annual Program Evaluation Reports, dated May 12, 2023 and May 12, 2022, reviewed on March 19, 2024 at 12:45 PM contained the same language each year as follows: "Mechanisms are in place to collect pertinent data to assist in the evaluation process and to monitor the care provided to the children through quarterly clinical record reviews and continuing review of clinical records each 62-day period. Children make progress, despite challenging obstacles, in the medical, developmental and educational domains. Children have: 1) weaned from ventilators, oxygen and feeding tubes...; 2) several of the children have been decannulated (tracheostomy tube removed); 3) reached developmental milestones as a result of a variety of therapeutic services...; 4) been discharged to competent trained caregivers. These impressive outcomes are, in large measure, a reflection of our staff's commitment to excellence."
Professional Advisory Committee Meeting Minutes, dated March 6, 2023 and March 22, 2022, reviewed on March 19, 2024 at 12:30 PM contained the same language each year as follows: "Quality Assurance Chart Review: Chart reviews for therapy services were completed by discipline-specific independent consultants for the past four quarters. During the reviews for the past couple of quarters, no issues were identified."
Clinical Record Reviews, conducted quarterly in 2022 and 2023, were reviewed on March 19, 2024 at 12:00 PM. The performance indicators contained in the review were as follows: "order present on plan of care; initial evaluation signed by physician and discipline; initial evaluation includes modalities/interventions/treatments; visit documented in clinical notes with signature and dates; frequency of visits complies with physician order; monthly review of treatment objectives present; documented physician notification of missed therapy visit; documented communication with members of team or family at least monthly; and discharge summary completed, if indicated."
Data from the clinical record reviews was collected individually per patient each quarter. There was no evidence that the data was compiled so that the effectiveness of the indicators/performance, in aggregate, could be evaluated, nor was there evidence that a change in indicators was considered given that the above-referenced Professional Advisory Committee meeting minutes noted "no issues" related to the same set of performance indicators reviewed over a two-year period. Outcome measures were not established.
There was no evidence of data collection related to outcomes documented in the quality assessment/performance improvement program, or the annual program evaluation reports for 2022 and 2023. There was no data to support that the governing body focused on indicators related to improved outcomes, the effectiveness of improvement efforts, nor was there evidence that the governing body provided clear expectations related to the implementation and maintenance of patient safety.
An interview with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.
Plan of Correction:By May 17 the board will receive information to review the Performance Improvement Indicators along with the performance improvement project.
During the quarterly board meeting on May 20, 2024 we will seek approval from the board for both the Performance Improvement Indicators and the performance improvement project. During the meeting board members will be given information regarding the Performance Improvement Indicators and asked to approve the identified indicator along with the method as to how the data will be collected and how the information will be used to improve quality. This will be reflected in the Board meeting minutes.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above.
Effective May 20,2024 the Program Evaluation will include summary and data regarding the Performance Improvement Project. This will be reflected in the board meeting minutes and approval obtained by board.
The Administrator or designee is responsible for completing the Program evaluation annually.
The Professional Advisory Committee will receive an email on May 1,2024 informing them of the Performance Improvement Project. At the annual PAC meeting a member of the Performance Improvement Committee will report on the project identified and the data collected.
During quarterly QA meetings a committee member will report on the project identified and the data collected.
The Performance Improvement Project Committee is responsible to ensure that the indicators address quality and safety of the patients.
The data will be presented to the Administrator quarterly by the Clinical Services Coordinator.
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 a home visit (HV) observation, review of agency policy and procedure, and an interview with the Clinical Services Coordinator, the agency failed to assure that acceptable standards of practice for infection control/prevention were maintained. One (1) of three (3) HV observations did not meet the requirement: PF# 5 (HV #3).
Findings include:
A review of the home health agency's (HHA) Policy and Procedure Infection Control - Facility Procedure #1, conducted on March 18, 2024 at 2:30 PM, reads in part "Purpose: To assure that both children and staff are as safe as possible from the risk of infection. Policy: Ken-Crest will do everything possible to maintain a safe environment in the residences and to eliminate or minimize conditions and practices that could expose children, visitors, or employees to injury or harm of any kind."
A home visit observation took place on March 19, 2024 between 2:00 PM and 2:30 PM. The home visit was observed by two (2) surveyors, the home health agency's clinical services coordinator, and a registered nurse (RN1) associated with the agency's Intermediate Care Facility (ICF) licensure. A physical therapist (PT) was observed to be providing treatment to a medically-complex, technologically-dependent child who was lying flat on a mat which was on the floor. During the course of the PT treatment, RN#1 was standing next to the mat observing the treatment. RN#1 then proceeded to walk on the mat that the child was lying on, with shoes on, in order to change the channel on the television (TV), and then walked on the mat again in order to return to his/her original position. There was no floor clearance to reach the TV since the position of the mat, immediately adjacent to various pieces of equipment, precluded the ability to walk directly on the floor. There was no attempt to clean the mat with a disinfectant or sanitizing agent after walking on it.
An interview conducted with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.
Plan of Correction:Effective April 4, 2024 the Ken-Care Home Health Agency Infection Control training has been revised to include additional information regarding equipment cleaning.
The revised policy will be emailed by April 9,2024 and mailed by April 12, 2024 to all current contracted and sub-contracted employees.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above changes.
All current employees, contracted and sub-contracted therapists, will receive training on the revised Infection Control Policy by May 13, 2024. The training will be provided by the Clinical Services Coordinator or designee.
The Clinical Services Coordinator and the Care Coordinator will be instructed by the Administrator to perform quarterly monitoring to ensure adherence to the policy.
The Clinical Services Coordinator or Care Coordinator will present findings of the monitoring to the Administrator at the QA meetings.
484.70(c) STANDARD
Infection control education
Name - Component - 00
Standard: Education.
The HHA must provide infection control education to staff, patients, and caregiver(s).
Observations:
Based on a review of personnel files, and an interview with the director, there was no evidence that staff received annual infection control education. Three (3) of six (6) personnel files did not meet the requirement: PF#4, PF#5, and PF#6.
Findings include:
A review of personnel files was conducted on March 18, 2024 starting at 11:00 AM. The start date (SD) is indicated below.
PF#4 SD 11/10/2020 did not contain evidence that annual infection control education was provided in 2022 or 2023. PF#4 is a contracted staff member.
PF#5 SD 04/17/2017 did not contain evidence that annual infection control education was provided in 2022 or 2023. PF#5 is a contracted staff member.
PF#6 SD 11/13/2007 did not contain evidence that annual infection control education was provided in 2022 or 2023. PF#6 is a contracted staff member.
An interview conducted with the Director and Administrator on March 20, 2024 confirmed the above findings.
Plan of Correction:Effective April 4, 2024 the Ken-Care Home Health Agency Infection Control training has been revised to include the requirement for annual Infection Control training for all current contracted and subcontracted employees.
The revised requirement will be emailed by April 9,2024 and mailed by April 12, 2024 to all current contracted and sub-contracted employees.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above changes.
All current employees, contracted and sub-contracted therapists will receive the annual Infection Control training on May 13, 2024. The training will be provided by the Clinical Services Coordinator.
All new employees contracted and subcontracted will be trained on the Infection Control Policy upon hire by the Clinical Services Coordinator or designee.
Going forward the annual training for all employees, contracted and subcontracted, will be conducted in the Month of May by the Clinical Services Coordinator or designee.
The Clinical Services Coordinator and the Care Coordinator will be instructed by the Administrator to perform quarterly monitoring to ensure adherence to the policy.
The Clinical Services Coordinator or Care Coordinator will present findings of the monitoring to the Administrator at the QA meetings.
484.105(b)(1)(iv) ELEMENT
Ensure that HHA employs qualified personnel
Name - Component - 00
(iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.
Observations:
Based on a review of personnel files (PF), contractual arrangements, email correspondence, therapist orientation checklist, and an interview with the director, the home health agency (HHA) failed to assure that the HHA employed qualified personnel. Three (3) of six (6) PF's reviewed did not meet the requirement: PF#4, PF#5, and PF#6.
Findings include:
A review of the contractual arrangement for therapy services (physical and occupational therapy) provided by Austill Rehabilitation Services (ARS) dated March 24, 2023 was conducted on March 18, 2024 at approximately 1:00 PM. The contract reads in part, "The Agency (Ken-Crest Services) has the ultimate responsibility for the administration or supervision of services provided."
An email exchange on February 9, 2024 at 9:08 AM between the HHA and ARS, reviewed on March 18, 2024 at approximately 1:15 PM, reads in part from ARS: "When PF#5 and PF#6 switched companies from Theraplay to Austill, they became independent contractors and we do not do performance evals for independent contractors, so they would not have anything for the years you mentioned - 2022, 2023, or 2024."
The Therapist Orientation Checklist, reviewed on March 18, 2024 at approximately 1:30 PM, contained the following information to be discussed/reviewed: "Job Description."
A review of personnel files was conducted on March 18, 2024 starting at 11:00 AM. The start date (SD) is indicated below.
PF#4 SD 11/10/2020 did not contain evidence of a signed job description at any time, nor was there evidence of annual performance evaluations for 2022 and 2023. PF#4 was a contracted staff member.
PF#5 SD 04/17/2017 did not contain evidence of a signed job description at any time, nor was there evidence of annual performance evaluations for 2022 and 2023. PF#5 was a contracted staff member.
PF#6 SD 11/13/2007 did not contain evidence of a signed job description at any time. PF#6 was a contracted staff member.
An interview conducted with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.
Plan of Correction:Effective April 12, 2024 all personnel files for contracted and subcontracted staff will contain a signed job description and a copy of annual performance appraisal.
This requirement will be shared by email on April 9, 2024 to all current contracted and sub-contracted staff.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above changes.
All current contracted and subcontracted employees will have a signed job description and annual performance evaluations in their personnel file by May 13, 2024.
Upon hire the Clinical Services Coordinated will review and obtain a signed job description from all contracted and subcontracted staff.
Annual performance evaluations for all contracted and subcontracted staff will be conducted the Alternate Administrator or designee.
The Clinical Services Coordinator and the Administrative Assistant will be instructed by the Administrator to perform quarterly monitoring to ensure adherence to the policy.
The Clinical Services Coordinator or Care Coordinator will present findings of the monitoring to the Administrator at the QA meetings.
Initial Comments:Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted March 18, 2024 through March 20, 2024, Ken-Care Home Health Agency 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(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 personnel files (PF), contractual arrangements, email correspondence, therapist orientation checklist, and an interview with the director, the home health agency (HHA) failed to assure that the HHA employed qualified personnel. Three (3) of six (6) PF's reviewed did not meet the requirement: PF#4, PF#5, and PF#6.
Findings include:
A review of the contractual arrangement for therapy services (physical and occupational therapy) provided by Austill Rehabilitation Services (ARS) dated March 24, 2023 was conducted on March 18, 2024 at approximately 1:00 PM. The contract reads in part, "The Agency (Ken-Crest Services) has the ultimate responsibility for the administration or supervision of services provided."
An email exchange on February 9, 2024 at 9:08 AM between the HHA and ARS reviewed on March 18, 2024 at approximately 1:15 PM reads in part from ARS: "When PF#5 and PF#6 switched companies from Theraplay to Austill, they became independent contractors and we do not do performance evals for independent contractors, so they would not have anything for the years you mentioned - 2022, 2023, or 2024."
The HHA's Therapist Orientation Checklist, reviewed on March 18, 2024 at approximately 1:30 PM contained the following information to be discussed/reviewed: "Job Description."
A review of personnel files was conducted on March 18, 2024 starting at 11:00 AM. The start date (SD) is indicated below.
PF#4 SD 11/10/2020 did not contain evidence of a signed job description at any time, nor was there evidence of annual performance evaluations for 2022 and 2023. PF#4 was a contracted staff member.
PF#5 SD 04/17/2017 did not contain evidence of a signed job description at any time, nor was there evidence of annual performance evaluations for 2022 and 2023. PF#5 was a contracted staff member.
PF#6 SD 11/13/2007 did not contain evidence of a signed job description at any time. PF#6 was a contracted staff member.
An interview conducted with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.
Plan of Correction:Effective April 12, 2024 all personnel files for contracted and subcontracted staff will contain a signed job description and a copy of annual performance appraisal.
This requirement will be shared by email on April 9, 2024 to all current contracted and sub-contracted staff.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above changes.
All current contracted and subcontracted employees will have a signed job description and annual performance evaluations in their personnel file by May 13, 2024.
Upon hire the Clinical Services Coordinated will review and obtain a signed job description from all contracted and subcontracted staff.
Annual performance evaluations for all contracted and subcontracted staff will be conducted the Alternate Administrator or designee.
The Clinical Services Coordinator and the Administrative Assistant will be instructed by the Administrator to perform quarterly monitoring to ensure adherence to the policy.
The Clinical Services Coordinator or Care Coordinator will present findings of the monitoring to the Administrator at the QA meetings.
Initial Comments:Based on the findings of an unannounced onsite Home Health Agency State Re-Licensure Survey conducted March 18, 2024 through March 20, 2024, Ken-Care Home Health Agency 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 Home Health Agency State Re-Licensure Survey conducted March 18, 2024 through March 20, 2024, Ken-Care Home Health Agency 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 observations of home health agency staff and an interview with the director, the agency failed to demonstrate evidence of requiring employees to wear a photo identification tag when the employee is working.
Findings include:
Observations of the home health agency's (HHA) staff from March 18, 2024, 9:30 AM through March 20, 2024, 12:30 PM found that no HHA staff were wearing identification badges.
The HHA Director, in an interview held on March 20, 2024 at approximately 9:15 AM, stated that the HHA does not use photo identification tags at this time.
An interview conducted with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.
Plan of Correction:Effective April 4, 2024 all staff of the Ken-Care Home Health agency are required to have and display photo ID.
This requirement will be shared by email on April 9, 2024 to all current contracted and sub-contracted employees.
The Alternate Administrator, Care Coordinator, Clinical Services Coordinator and Administrative Assistant have all been instructed by the Administrator on the above changes.
All current employees, contracted and sub-contracted therapists, will receive their photo ID by May 13, 2024. All new employees will receive photo IDs upon hire. The Clinical Services Coordinator or designee is responsible to ensure that all photo IDs are received.
The Clinical Services Coordinator and the Care Coordinator will be instructed by the Administrator to perform quarterly monitoring to ensure adherence to the policy.
The Clinical Services Coordinator or Care Coordinator will present findings of the monitoring to the Administrator at the QA meetings.
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