QA Investigation Results

Pennsylvania Department of Health
CROZER KEYSTONE HOME HEALTH
Health Inspection Results
CROZER KEYSTONE HOME HEALTH
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone Home Health Agency was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.




Plan of Correction:




484.60(b) STANDARD
Conformance with physician orders

Name - Component - 00
Standard: Conformance with physician orders.

Observations:


Based on review of agency ' s policies and procedures, clinical records (CR), and interview with the agency staff, it was determined that the agency failed to ensure physician ' s orders were followed for Occupational Therapy assessment and evaluation for one (1) of seventeen (17) clinical records (CR) reviewed (CR #11).

Findings include:

Review of agency policy titled "Assessment Documentation - Section 2.5", on May17, 2021 at approximately 9:45AM, policy states, " ....After the initial assessment, referred disciplines will complete discipline specific assessments within seven (7) days ....D. Confirmed missed visits: Missed visit reasons will be documented under visit management, and the MD or designee will be notified .... "

A review of clinical records conducted on May 11, 2021, at approximately 2:10PM and May 12, 2021 at approximately 10:15AM, revealed the following:

CR #11, start of care 2/14/2021. Certification period 2/14/2021 through 4/14/2021 - Contained orders for Occupational Therapy (OT) (2/8/2021 - 2/22/2021): Assess and Evaluation.

Review of the OT visit documentation on 5/11/2021 at approximately 3:00PM and 5/12/2021 at approximately 10:45AM, revealed an initial evaluation was scheduled for 2/22/2021. However, this visit was missed, and no subsequent visit was scheduled thereafter. There was no documentation that physician was notified that the initial OT evaluation was not made.

Interview with alternate administrator on 5/12/2021 at approximately 11:00AM, alternate administrator stated, that shortly after 2/22/2021, CR #11 was hospitalized, and upon her hospital discharge, CR #11 only received orders for SN.

CR #11 was discharged from agency on 4/12/2021.

Interview with administrator on 5/13/2021 at 1:30PM confirmed the above findings.





Plan of Correction:

484.60 (b) Plan of Care Standard -Conformance with Physician Orders



Corrective action to be completed:
- Clinicians will be reeducated on assuring physician orders are in alignment with the plan of care for each discipline.

- All clinicians will receive education on policy entitled Assessment Documentation (Policy 2.5) as it relates to missed visit management including documentation of missed visit with reason and physician notification.

- Monthly audits of patients currently on census will be conducted to assure compliance with documentation of physician notification of confirmed missed visits.
- Monitoring will occur for a timeframe of 3months and until a sustained compliance rate of 90% is assured.




484.110(a) STANDARD
Contents of clinical record

Name - Component - 00
Standard: Contents of clinical record. The record must include:

Observations:


Based on review of agency ' s policies and procedures, clinical records (CR), and interview with the agency staff, it was determined that the agency failed to follow its procedure to ensure physician was notified of missed visits and that missed visits were documented in clinical record for two (2) of seventeen (17) clinical records (CR) reviewed (CR #3 and #11).

Findings include:

Review of agency policy titled "Assessment Documentation - Section 2.5", on May17, 2021 at approximately 9:45AM, policy states, " ....After the initial assessment, referred disciplines will complete discipline specific assessments within seven (7) days ....D. Confirmed missed visits: Missed visit reasons will be documented under visit management, and the MD or designee will be notified .... "

A review of clinical records conducted on May 11, 2021, at approximately 2:10PM and May 12, 2021 at approximately 10:15AM, revealed the following:

CR #3, start of care 3/21/2021. Certification period 3/21/2021 through 5/19/2021 - Contained orders for Home Health Aide (HHA) (3/28/2021 - 5/15/2021): One (1) HHA visit per week for seven (7) weeks.

Review of the HHA visit documentation on 5/11/2021 at approximately 2:10PM and 5/12/2021 at approximately 10:20AM, revealed a missed visit on 4/6/2021. There was no documentation that physician was notified of missed visit.

CR #11, start of care 2/14/2021. Certification period 2/14/2021 through 4/14/2021 - Contained orders for Occupational Therapy (OT) (2/8/2021 - 2/22/2021): Assess and Evaluation.

Review of the OT visit documentation on 5/11/2021 at approximately 3:00PM and 5/12/2021 at approximately 10:45AM, revealed an initial evaluation was scheduled for 2/22/2021. However, this visit was missed, and no subsequent visit was scheduled thereafter. There was no documentation that physician was notified that the initial OT evaluation was not made.

Interview with administrator on 5/13/2021 at 1:30PM confirmed the above findings.





Plan of Correction:

484.110 Contents of Clinical Record Corrective action to be completed:
- All clinicians will receive Education on documentation standards
- including review of policy "Assessment Documentation" (Policy2.5) as it relates to missed visit management including documentation of missed visit with reason and physician notification.
- Home Health Aides will be reeducated on process for missed visits.
- Scheduler will be reeducated on process for HHA missed visits.
- Monthly audits will be conducted to assure compliance with missed visits documentation.
- Monitoring will occur for a timeframe of 3 months and until 90% compliance is assured.




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone 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 onsite unannounced Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone 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:




601.31(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 review of agency ' s policies and procedures, clinical records (CR), and interview with the agency staff, it was determined that the agency failed to ensure physician ' s orders were followed for Occupational Therapy assessment and evaluation for one (1) of seventeen (17) clinical records (CR) reviewed (CR #11).

Findings include:

Review of agency policy titled "Assessment Documentation - Section 2.5", on May17, 2021 at approximately 9:45AM, policy states, " ....After the initial assessment, referred disciplines will complete discipline specific assessments within seven (7) days ....D. Confirmed missed visits: Missed visit reasons will be documented under visit management, and the MD or designee will be notified .... "

A review of clinical records conducted on May 11, 2021, at approximately 2:10PM and May 12, 2021 at approximately 10:15AM, revealed the following:

CR #11, start of care 2/14/2021. Certification period 2/14/2021 through 4/14/2021 - Contained orders for Occupational Therapy (OT) (2/8/2021 - 2/22/2021): Assess and Evaluation.

Review of the OT visit documentation on 5/11/2021 at approximately 3:00PM and 5/12/2021 at approximately 10:45AM, revealed an initial evaluation was scheduled for 2/22/2021. However, this visit was missed, and no subsequent visit was scheduled thereafter. There was no documentation that physician was notified that the initial OT evaluation was not made.

Interview with alternate administrator on 5/12/2021 at approximately 11:00AM, alternate administrator stated, that shortly after 2/22/2021, CR #11 was hospitalized, and upon her hospital discharge, CR #11 only received orders for SN.

CR #11 was discharged from agency on 4/12/2021.

Interview with administrator on 5/13/2021 at 1:30PM confirmed the above findings.





Plan of Correction:

M1020 Conformance with Physician orders Corrective action to be completed:
- Clinicians will be reeducated on assuring physician orders are in alignment with the plan of care for each discipline.

- All clinicians will receive education on policy entitled Assessment Documentation (Policy 2.5) as it relates to missed visit management including documentation of missed visit with reason and physician notification.

- Monthly audits of patients currently on census will be conducted to assure compliance with documentation of physician notification of confirmed missed visits.
- Monitoring will occur for a timeframe of 3months and until a sustained compliance rate of 90% is assured.




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone 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 onsite unannounced Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone Home Health Agency was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: