QA Investigation Results

Pennsylvania Department of Health
CONCORDIA VISITING NURSES
Health Inspection Results
CONCORDIA VISITING NURSES
Health Inspection Results For:


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Initial Comments:Based on the findings of an onsite unannounced complaint investigation completed October 20, 2022, Concordia Visiting Nurses 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. The survey was conducted at the Cabot location.


Plan of Correction:




484.50(d)(1) ELEMENT
HHA can no longer meet the patient's needs

Name - Component - 00
The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities;

Observations: Based on review of agency policy, a clinical record (CR), and staff (EMP) interview, the agency failed to arrange a safe and appropriate transfer of care to another care entities when the needs of the patient exceeded the HHA's capabilities for one (1) of one (1) clinical record who was discharged (CR1). Findings included: Review of agency policy on October 19, 2022, at 12 p.m. showed, "SUBJECT: Transfer of Patients ... Policy: VII-3 ... I. Policy It shall be the policy of Concordia Visiting Nurses to provide orderly transfer of patients and their records in circumstances where another service provider is need ... Continuity of care is a priority in the event Concordia Visiting Nurses is unable to maintain or deliver Home Health Services. II. Procedure A. Concordia Visiting Nurses patient(s) will be referred to another agency due to any of the following circumstances: 1. If the patient's needs cannot be met by this Agency ... 4. If there are safety concerns for agency staff within the patient's home. 5. If the patient does not meet the Patient Responsibilities as outlined in the Patient Information Booklet. ... J. Transfer of any Agency patients to another level of care: Once the agency becomes aware of the transfer, notification shall be given to the: ... The new service provider. K. Selection of Successor, if applicable: The patient will be given a list of available providers for the selection of a successor. New providers are notified as per procedure." Review of CR1 on October 19, 2022, at 10 a.m. showed a physician ordered plan of care with an initial certification period from 8/19/2022 to 10/17/2022. Patient had private insurance with an admitting diagnoses included wounds, hypertension, diabetes, and below knee amputations. Skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services were ordered. Per the plan of care, SN was to perform wound care. The patient was to perform wound care on days when agency was not in the home. Eighteen SN visits from start of care on 8/19 to 10/3/2022 showed the patient was self-neglecting and not participating in his care. On 8/27/2022, the patient refused physical therapy evaluation and services. The patient had difficulty walking related to double below knee amputations. On 8/29/2022, the patient refused OT services. During this time the patient refused to follow his plan of care concerning managing his diabetes with blood sugar checks, taking insulin and other ordered medications. The patient refused to participate in his plan of care and refused to perform dressing changes to wounds on days when SN was not providing services. SN nursing provided education throughout the episode concerning the detriments of not following the plan of care and taking prescribed medication but CR1 refused to comply with necessary care. On 9/27/2022, during case conference, it was noted that patient was alert and orientated and could verbalize how to perform dressing changes but that he did not want to do it. The conference noted continued non-compliance with the plan of treatment. Agency decided to move ahead with physician approved patient contract for safety. During a home visit on 9/28/2022, a registered nurse and social worker presented the patient a contract for safety, but he refused to sign. The contract included, "CARE COMPLAINCE CONTRACT ... This agreement is between [CR1] and Concordia Visiting Nurses In an effort to better care for you, the following expectations are required to maintain an effective provider-patient relationship CARE EXPECTATION 1. I understand that I am accountable for my outcomes, if I refuse care or do not follow the plan of care as ordered by my doctor. 2. I understand that I need to be compliant with the current wound care orders. This is to include but not limited to learning wound care, understanding the need for current wound care, and demonstrating ability to perform wound care. 3. I agree to be compliant with testing blood sugars, which will help prevent worsening of my already existing conditions and try to improve my current health status, as well as taking ordered medications as prescribed to aid in preventing exacerbations of current health conditions. 4. I understand that it is my responsibility to permit agency staff to perform assessment that includes examining all skin including buttocks for potential skin breakdown." The social worker documented that she told the patient he would most likely be discharged since he refused to contract for safety. According to physician's order, "Order Date: 10/3/2022 ... Agency DC week of 10/3/2022 following setting up new home health agency for wound care." Per coordination note, "10/5/2022 ... Called MD office to see where we were at with the need for patient to secure referral to another agency. [Attending physician] has notes in system ... he doesn't think going to another agency will change anything and he feels there's no way to make him [patient] more compliant -- however [they] are going to have [case manager] try to set the referral up with [another home health agency]." Per coordination note on 10/6/2022 the patient chose another home health agency but Concordia failed to contact the receiving agency, "Patient called RN following follow up appointment with [new wound clinic doctor] through [another provider associated with another home health agency]. Patient was taken under services with [different] wound care center. Per patient MD was going to make referral to [...] home health per patient's request. RN informed patient he is on RNs schedule for 10/7/2022 for a phone discharge and that RN would call [new wound clinic doctor]'s office in AM to follow up about a new home care agency and would then call patient for DC. RN called [new wound clinic doctor]'s office and spoke with [RN] who stated referral was sent to [...] home care and patient was accepted." Per coordination note from 10/13/2022, wound clinic called agency and noted that they were unable to find patient another agency-- patient is currently back on service with Concordia visiting nurses and remains non-compliant. Interviews with EMP1 and EMP3 on October 19, 2022, from 12 p.m. to 1 p.m., and a phone interview with EMP3 on October 20, 2022, confirmed the above findings and that patient was discharged on 10/7/2022. Concordia Visiting Nurses never made direct contact with the receiving home health agency to coordinate a safe transfer of care but instead relied on staff at wound clinic (a third party) to arrange the referral and transfer to another home health agency. EMP3 confirmed that Concordia was communicating with the wound clinic for patient's referral and that the wound clinic's parent company never sent the referral to the parent company's home health agency. The reliance on a third party for referral and transfer of care instead of coordinating directly with the receiving home health agency caused a delay in patient's care-- 10 days without services.

Plan of Correction:

How will the agency correct the deficiency?
- After CVN communicated with the other home health agency on 10/14/2022 it was discovered that the other agency did not admit the patient. CVN reversed the discharge and visited the patient on 10/14/2022, to provide wound care and other nursing services. Patient was recertified for another episode of care on 10/17/2022, and CVN continues to care for the patient as per physician orders.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided to all discharging staff to review the agency's Discharge and Transfer Policies and steps to take for appropriate discharge planning and coordination of care.
- The agency will create an agency-to-agency transfer checklist to be used with all transfers to ensure all required items are completed with each transfer of care.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audit all transfers of care for the next 60 days to ensure that all proper processes were followed per agency policy. Auditing to be completed by the Director of Compliance or designee and will begin 11/21/2022.



484.50(d)(5)(iii) ELEMENT
Provide contact info other services

Name - Component - 00
(iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and

Observations: Based on review of agency policy, a clinical record (CR), and staff (EMP) interview, the agency failed to provide the patient with contact information for other agencies or providers who may be able to provide care prior to discharge for one (1) of one (1) discharged record (CR1). Findings included: Review of agency policy on October 19, 2022, at 12 p.m. showed, "SUBJECT: Discharge Policy .... Policy: VII-4 ... II. Procedure ... E. Discharge occurs in the following situations: ... 12. The patient/caregiver is unable or unwilling to participate in care necessary to support a safe level of care and/or progress towards established goals. The clinical record should reflect: ... There should be evidence in the clinical record that the patient and/or representative was provided information including contact numbers for other agencies or providers that may be able to provide services to the patient. The physician and patient are both notified of this decision both verbally and in writing." "SUBJECT: Transfer of Patients ... Policy: VII-3 ... I. Policy It shall be the policy of Concordia Visiting Nurses to provide orderly transfer of patients and their records in circumstances where another service provider is need ... Continuity of care is a priority in the event Concordia Visiting Nurses is unable to maintain or deliver Home Health Services. ... J. Transfer of any Agency patients to another level of care: ... The patient will be given a list of available providers for the selection of a successor. New providers are notified as per procedure." Review of CR1 on October 19, 2022, at 10 a.m. showed a physician ordered plan of care with an initial certification period from 8/19/2022 to 10/17/2022. Patient had private insurance with an admitting diagnoses included wounds, hypertension, diabetes, and below knee amputations. Skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services were ordered. Per the plan of care, SN was to perform wound care. The patient was to perform wound care on days when agency was not in the home. Eighteen SN visits from start of care on 8/19 to 10/3/2022 showed the patient was self-neglecting and not participating in his care. On 8/27/2022, the patient refused physical therapy evaluation and services. The patient had difficulty walking related to double below knee amputations. On 8/29/2022, the patient refused OT services. During this time the patient refused to follow his plan of care concerning managing his diabetes with blood sugar checks, taking insulin and other ordered medications. The patient refused to participate in his plan of care and refused to perform dressing changes to wounds on days when SN was not providing services. SN nursing provided education throughout the episode concerning the detriments of not following the plan of care and taking prescribed medication but CR1 refused to comply with necessary care. On 9/27/2022, during case conference, it was noted that patient was alert and orientated and could verbalize how to perform dressing changes but that he does not want to do it. The conference noted continued non-compliance with the plan of treatment. Agency decided to move ahead with physician approved patient contract for safety. During a home visit on 9/28/2022, a registered nurse and social worker presented the patient a contract for safety, but he refused to sign. The contract included, "CARE COMPLAINCE CONTRACT ... This agreement is between [CR1] and Concordia Visiting Nurses In an effort to better care for you, the following expectations are required to maintain an effective provider-patient relationship CARE EXPECTATION 1. I understand that I am accountable for my outcomes, if I refuse care or do not follow the plan of care as ordered by my doctor. 2. I understand that I need to be compliant with the current wound care orders. This is to include but not limited to learning wound care, understanding the need for current wound care, and demonstrating ability to perform wound care. 3. I agree to be compliant with testing blood sugars, which will help prevent worsening of my already existing conditions and try to improve my current health status, as well as taking ordered medications as prescribed to aid in preventing exacerbations of current health conditions. 4. I understand that it is my responsibility to permit agency staff to perform assessment that includes examining all skin including buttocks for potential skin breakdown." The social worker documented that he/she told the patient he would most likely be discharged since he refused to contract for safety. According to physician's order, "Order Date: 10/3/2022 ... Agency DC week of 10/3/2022 following setting up new home health agency for wound care." Per coordination note, "10/6/2022 ... Patient called RN following follow up appointment with [new wound clinic doctor] through [another provider associated with another home health agency]. Patient was taken under services with [different] wound care center. Per patient MD was going to make referral to [...] home health per patient's request. RN informed patient he is on RNs schedule for 10/7/2022 for a phone discharge and that RN would call [new wound clinic doctor]'s office in AM to follow up about a new home care agency and would then call patient for DC. RN called [new wound clinic doctor]'s office and spoke with [RN] who stated referral was sent to [...] home care and patient was accepted." Interviews with EMP1 and EMP3 on October 19, 2022, from 12 p.m. to 1 p.m. confirmed patient was discharged from agency on 10/7/2022 without first receiving contact information for other agencies or providers who may be able to provide care.

Plan of Correction:

How will the agency correct the deficiency?
- After CVN communicated with the other home health agency on 10/14/2022 it was discovered that the other agency did not admit the patient. CVN reversed the discharge and visited the patient on 10/14/2022, to provide wound care and other nursing services. Patient was recertified for another episode of care on 10/17/2022, and CVN continues to care for the patient as per physician orders.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided to all discharging staff to review the agency's Discharge and Transfer Policies and steps to take for appropriate discharge planning and coordination of care.
- The agency will create an agency-to-agency transfer checklist to be used with all transfers to ensure all required items are completed with each transfer of care.

Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audit all transfers of care for the next 60 days to ensure that all proper processes were followed per agency policy. Auditing to be completed by the Director of Compliance or designee and will begin 11/21/2022.



484.60(d)(4) ELEMENT
Coordinate care delivery

Name - Component - 00
Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.

Observations: Based on review of a clinical record (CR), and staff (EMP) interview, the agency failed coordinate care to meet the needs of the patient for one (1) of one (1) patient who was discharged (CR1). FIndings included: Review of CR1 on October 19, 2022, at 10 a.m. showed a physician ordered plan of care with an initial certification period from 8/19/2022 to 10/17/2022. Patient had private insurance with an admitting diagnoses included wounds, hypertension, diabetes, and below knee amputations. Skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services were ordered. Per the plan of care, SN was to perform wound care. The patient was to perform wound care on days when agency was not in the home. According to physician's order, "Order Date: 10/3/2022 ... Agency DC week of 10/3/2022 following setting up new home health agency for wound care." Per coordination note, "10/5/2022 ... Called MD office to see where we were at with the need for patient to secure referral to another agency. [Attending physician] has notes in system ... he doesn't think going to another agency will change anything and he feels there's no way to make him [patient] more compliant -- however [they] are going to have [case manager] try to set the referral up with [another home health agency]." Per coordination note, "10/6/2022 ... Patient called RN following follow up appointment with [new wound clinic doctor] through [another provider associated with another home health agency]. Patient was taken under services with [different] wound care center. Per patient MD was going to make referral to [...] home health per patient's request. RN informed patient he is on RNs schedule for 10/7/2022 for a phone discharge and that RN would call [new wound clinic doctor]'s office in AM to follow up about a new home care agency and would then call patient for DC. RN called [new wound clinic doctor]'s office and spoke with [RN] who stated referral was sent to [...] home care and patient was accepted." Per coordination note from 10/13/2022, wound clinic called agency and noted that they were unable to find patient another agency-- patient is currently back on service with Concordia visiting nurses and remains non-compliant. Interviews with EMP1 and EMP3 on October 19, 2022, from 12 p.m. to 1 p.m., and a phone interview with EMP3 on October 20, 2022, confirmed the above findings. Concordia Visiting Nurses never made direct contact with the receiving home health agency to coordinate a safe transfer of care but instead relied on staff at wound clinic (a third party) to arrange for referral and transfer to another home health agency. EMP3 confirmed that Concordia was communicating with the wound clinic for patient's referral and that the wound clinic's parent company never sent the referral to the parent company's home health agency. The reliance on a third party for referral and transfer of care instead of coordinating directly with receiving home health agency caused a delay in patient's care-- 10 days without services.

Plan of Correction:

How will the agency correct the deficiency?
- After CVN communicated with the other home health agency on 10/14/2022 it was discovered that the other agency did not admit the patient. CVN reversed the discharge and visited the patient on 10/14/2022, to provide wound care and other nursing services. Patient was recertified for another episode of care on 10/17/2022, and CVN continues to care for the patient as per physician orders.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided to all discharging staff to review the agency's Discharge and Transfer Policies and steps to take for appropriate discharge planning and coordination of care.
- The agency will create an agency-to-agency transfer checklist to be used with all transfers to ensure all required items are completed with each transfer of care.
-With each transfer/discharge, the Clinical Manager or designee will call the receiving agency directly during the referral process to ensure the patient will be seen timely with the new agency. This call will be documented on the Transfer checklist. Any other communication with receiving agency will be documented in the patient's medical record.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audit all transfers of care for the next 60 days to ensure that all proper processes were followed per agency policy. Auditing to be completed by the Director of Compliance or designee and will begin 11/21/2022.



Initial Comments:Based on the findings of an onsite unannounced complaint investigation completed October 20, 2022, Concordia Visiting Nurses was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.


Plan of Correction:




Initial Comments:Based on the findings of an onsite unannounced complaint investigation completed October 20, 2022, Concordia Visiting Nurses was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.


Plan of Correction:




51.3 (f) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations: Based on review of a clinical record (CR), the Department's event reporting system (ERS) and its manual, and staff (EMP) interview, the agency failed to report incidents that could seriously compromise quality assurance or patient safety. The agency failed to report an instance of neglect for one (1) of one (1) patient who was discharged (CR1) Findings included: Per the Department's ERS Manual, "PA Department of Health (PA-DOH) Event Notification Internet Site Overview - Facilities ... Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions. All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System is the mechanism the Department will use to meet this regulatory requirement. ... The following is a list of all Categories that should be submitted: ... Patient/resident neglect." Findings included: Review of CR1 on October 19, 2022, at 10 a.m. showed a physician ordered plan of care with an initial certification period from 8/19/2022 to 10/17/2022. Patient is 55-year-old male with private insurance. Patient's admitting diagnoses included wounds, hypertension, diabetes, and below knee amputations. Skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services were ordered. Per the plan of care, SN was to perform wound care, and the patient was to perform wound care when agency was not in the home. Subsequent SN visits on 8/24/2022, and 8/26/2022 found patient living in a foul smelling and cluttered hotel room with rotting food present. On 8/27/2022, the patient refused physical therapy evaluation and services. The patient had difficulty walking because he was a double below knee amputee. On 8/29/2022, the patient refused OT services. Additional SN visits from 8/30 to 10/3/022 found the patient continued to live in a foul smelling and cluttered hotel room. During this time the patient refused to follow his plan of care concerning managing his diabetes with blood sugar checks, taking insulin and other ordered medications. The capable patient refused to participate in his plan of care and refused to perform dressing changes to wounds on days when SN was not providing services. SN nursing provided education throughout the episode concerning the detriments of not following the plan of care and taking prescribed medication but CR1 refused to comply with necessary care. Review of ERS on October 20, 2022, at 10 a.m. did not show the above instance of self-neglect was reported. Per phone interview with EMP3 on October 20, 2022, at 1:45 p.m., confirmed above findings and noted, "probably not submitted," because protectives services was already involved pre-home health admission when patient resided at a skilled nursing facility.

Plan of Correction:

How will the agency will correct the deficiency?
- Event Report was submitted on 10/21/2022.
Measures or systems the Agency will alter to ensure the problem does not occur:
- All clinical staff will be educated on the agency's Mandatory Event Reporting policy.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- A random sample of 5 charts per month will be reviewed until 100% compliance is met to ensure proper reporting to the DoH has been completed. Auditing will be completed by the Director of Compliance or designee and will begin 11/21/2022.