Initial Comments:
Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, Extended Family Care 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:
484.60(a)(3) ELEMENT
All orders recorded in plan of care
Name - Component - 00
All patient care orders, including verbal orders, must be recorded in the plan of care.
Observations:
Based on review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the Plan of Care (POC) included updated frequency orders for nine (9) of fourteen (14) CRs reviewed
(CR 1-4, 6-9, and 12).
Findings included:
Review of agency policy on 2/29/24 at approximately 2:00pm revealed:
..."MEDICAL SUPERVISION/MEDICAL ORDERS...PROCEDURE...6. Medical orders must contain the following: ...b. Types amount and duration of services desired; ..."
Review of clinical records on 3/1/24 between approximately 9:00am and 1:30pm revealed:
CR1, start of care date 6/1/23, dates reviewed 10/29/23-1/1/24. Frequency order on plan of care (POC) for skilled nurse services 5-10 hours/night, 3-7 nights/week for 60 days. Effective date 6/1/23, with an end date of 7/31/23. POC failed to include frequency and duration of services for dates reviewed.
CR2, start of care date 4/1/23, dates reviewed 4/1/23-4/30/23. Frequency order on POC for home health aide services 5-10 hours/day, 3-5 days/week for 60 days. Effective date 7/15/21, with an end date of 9/13/21. POC failed to include frequency and duration of services for dates reviewed.
CR3, start of care date 12/22/23, dates reviewed 1/21/24-2/29/24. Frequency order on POC for home health aide services 10-40 hours/week, 3-7 days/week flex for 60 days. Effective date 12/22/23, with an end date of 2/20/24. POC failed to include frequency and duration of services for dates reviewed after 2/20/24.
CR4, start of care date 11/21/23, dates reviewed 1/20/24-2/29/24. Frequency order on POC for home health aide services 2-5 hours/day Monday-Friday on school days and 4-8 hours/day Monday-Friday on non-school days for 60 days. Effective date 12/15/23, with an end date of 2/13/24. POC failed to include frequency and duration of services for dates reviewed after 2/13/24.
CR6, start of care date 5/18/23, dates reviewed 5/18/23-7/22/23. Frequency order on POC for home health aide services in lieu of skilled nurse services: 40-84 hours/week, 3-7 days/week for 60 days. Effective date 5/18/23, with an end date of 7/17/23. POC failed to include frequency and duration of services for dates reviewed.
CR7, start of care date 10/2/23, dates reviewed 1/30/24-2-29-24. Frequency order on POC for home health aide services 20-40 hours/day, 3-7 days/week for 60 days. Effective date 10/2/23, with an end date of 12/1/23. POC failed to include frequency and duration of services for dates reviewed.
CR8, start of care date 2/11/21, dates reviewed 1/27/24-2/29/24. Frequency order on POC for home health aide services 4-9 hours on school days and 8-11 hours on non-school days for 60 days. Effective date 2/12/21, with an end date of 4/13/21. POC failed to include frequency and duration of services for dates reviewed.
CR9, start of care date 1/14/21, dates reviewed 12/30/23-2/27/24. Frequency order on POC for home health aide services 20-40 hours/week, 4-6 days/week for 60 days. Effective date 1/14/21, with an end date of 3/15/21. POC failed to include frequency and duration of services for dates reviewed.
CR12, start of care date 12/1/22, dates reviewed 1/20/24-2/28/24. Frequency order on POC for skilled nurse services 60-112 hours/week, 5-7 days/week for 60 days. Effective date 2/1/21, with an end date of 4/2/21. POC failed to include frequency and duration of services for dates reviewed.
Exit interview on March 1, 2024, at 2:30pm with the Administrator, and Director of Patient Services, Senior Patient Care Advocate, and Referral Specialist confirmed findings.
Plan of Correction:The Administrator, along with the Director of Patient Services will ensure the following:
DPS and Nursing Supervisors will review and audit All client's Plan of Care (POC)
to ensure they include updated frequency orders for each client on service with effective dates of current certification period.
Templates in Devaro clinical software system have been updated to ensure frequency orders reflect current certification periods for all clients.
DPS will create In-Service and have education training with all Nursing Supervisors so they understand the process moving forward and obtain proper frequency orders
Administrator and DPS will audit all client charts weekly and review POC orders to ensure all will be updated for next certification period to ensure all clients have updated frequency orders by April 30, 2024.
Initial Comments:Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, Extended Family Care was found not to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
484.102(c)(1) STANDARD
Names and Contact Information
Name - Component - 00
§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).
[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.
*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.
*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.
*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.
*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Based on review of agency policy and procedure and staff (EMP) interview, the agency failed to ensure the Emergency Preparedness communication plan included names and contact information for staff.
Findings included:
Review of agency Emergency Preparedness Plan on 2/29/24 at approximately 2:00pm revealed:
"Emergency Preparedness Plan... Agency Wide Plan for Disaster in Service Area...5. The DPS [Director of Professional Services]/designee will initiate a "call down" using the phone tree to assess availability of all staff..."
Review of the Emergency Preparedness documentation in conjunction with policy review determined absence of phone tree.
Interview with DPS, Senior Patient Care Advocate, and Referral Specialist on 3/1/24 at approximately 2:00pm revealed inability to produce evidence of phone tree.
Exit interview on March 1, 2024, at 2:30pm with the Administrator, and Director of Patient Services, Senior Patient Care Advocate, and Referral Specialist confirmed findings.
Plan of Correction:The Administrator will ensure that the Emergency Preparedness communication plan includes names and contact information for all staff and that all administrative staff are aware of procedures and where to obtain and gather all pertinent information when needed. Administrator will also ensure all staff maintain updated contact information for staff when that changes and updates are made.
Administrative staff will be made aware exactly where the Phone tree master is and we will hold mock drills 2 times per year to ensure competency in Emergency communication. Education will be provided to all. In-Service and education will be signed off on by all administrative employees.
Administrator will hold an In-Service for all administrative staff to ensure they are aware of Extended Family Care Pittsburgh Emergency Preparedness Plan, Phone Tree, and Tabletop Drills along with after action report.
Administrator will also reach out to local contact to enrich and improve Emergency Plan in its entirety.
Initial Comments:Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, Extended Family Care was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.31(b) REQUIREMENT
PLAN OF TREATMENT
Name - Component - 00
601.31(b) Plan of Treatment. The
plan of treatment developed in
consultation with the agency staff
covers all pertinent diagnoses,
including:
(i) mental status,
(ii) types of services and equipment
required,
(iii) frequency of visits,
(iv) prognosis,
(v) rehabilitation potential,
(vi) functional limitations,
(vii) activities permitted,
(viii) nutritional requirements,
(ix) medications and treatments,
(x) any safety measures to protect
against injury,
(xi) instructions for timely
discharge or referral, and
(xii) any other appropriate items.
(Examples: Laboratory procedures and
any contra-indications or
precautions to be observed).
If a physician refers a patient under
a plan of treatment which cannot be
completed until after an evaluation
visit, the physician is consulted to
approve additions or modifications to
the original plan.
Orders for therapy services include
the specific procedures and modalities
to be used and the amount, frequency,
and duration.
The therapist and other agency
personnel participate in developing
the plan of treatment.
Observations:
Based on review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to ensure the Plan of Care (POC) included updated frequency orders for nine (9) of fourteen (14) CRs reviewed
(CR 1-4, 6-9, and 12).
Findings included:
Review of agency policy on 2/29/24 at approximately 2:00pm revealed:
..."MEDICAL SUPERVISION/MEDICAL ORDERS...PROCEDURE...6. Medical orders must contain the following: ...b. Types amount and duration of services desired; ..."
Review of clinical records on 3/1/24 between approximately 9:00am and 1:30pm revealed:
CR1, start of care date 6/1/23, dates reviewed 10/29/23-1/1/24. Frequency order on plan of care (POC) for skilled nurse services 5-10 hours/night, 3-7 nights/week for 60 days. Effective date 6/1/23, with an end date of 7/31/23. POC failed to include frequency and duration of services for dates reviewed.
CR2, start of care date 4/1/23, dates reviewed 4/1/23-4/30/23. Frequency order on POC for home health aide services 5-10 hours/day, 3-5 days/week for 60 days. Effective date 7/15/21, with an end date of 9/13/21. POC failed to include frequency and duration of services for dates reviewed.
CR3, start of care date 12/22/23, dates reviewed 1/21/24-2/29/24. Frequency order on POC for home health aide services 10-40 hours/week, 3-7 days/week flex for 60 days. Effective date 12/22/23, with an end date of 2/20/24. POC failed to include frequency and duration of services for dates reviewed after 2/20/24.
CR4, start of care date 11/21/23, dates reviewed 1/20/24-2/29/24. Frequency order on POC for home health aide services 2-5 hours/day Monday-Friday on school days and 4-8 hours/day Monday-Friday on non-school days for 60 days. Effective date 12/15/23, with an end date of 2/13/24. POC failed to include frequency and duration of services for dates reviewed after 2/13/24.
CR6, start of care date 5/18/23, dates reviewed 5/18/23-7/22/23. Frequency order on POC for home health aide services in lieu of skilled nurse services: 40-84 hours/week, 3-7 days/week for 60 days. Effective date 5/18/23, with an end date of 7/17/23. POC failed to include frequency and duration of services for dates reviewed.
CR7, start of care date 10/2/23, dates reviewed 1/30/24-2-29-24. Frequency order on POC for home health aide services 20-40 hours/day, 3-7 days/week for 60 days. Effective date 10/2/23, with an end date of 12/1/23. POC failed to include frequency and duration of services for dates reviewed.
CR8, start of care date 2/11/21, dates reviewed 1/27/24-2/29/24. Frequency order on POC for home health aide services 4-9 hours on school days and 8-11 hours on non-school days for 60 days. Effective date 2/12/21, with an end date of 4/13/21. POC failed to include frequency and duration of services for dates reviewed.
CR9, start of care date 1/14/21, dates reviewed 12/30/23-2/27/24. Frequency order on POC for home health aide services 20-40 hours/week, 4-6 days/week for 60 days. Effective date 1/14/21, with an end date of 3/15/21. POC failed to include frequency and duration of services for dates reviewed.
CR12, start of care date 12/1/22, dates reviewed 1/20/24-2/28/24. Frequency order on POC for skilled nurse services 60-112 hours/week, 5-7 days/week for 60 days. Effective date 2/1/21, with an end date of 4/2/21. POC failed to include frequency and duration of services for dates reviewed.
Exit interview on March 1, 2024, at 2:30pm with the Administrator, and Director of Patient Services, Senior Patient Care Advocate, and Referral Specialist confirmed findings.
Repeat deficiency, previously cited: 3/26/12, 3/31/15, and 3/16/21.
Plan of Correction:The Administrator, along with the Director of Patient Services will ensure the following:
DPS and Nursing Supervisors will review and audit All client's Plan of Care (POC) to ensure they include updated frequency orders for each client on service with effective dates of current certification period.
Templates in Devaro clinical software system have been updated to ensure frequency orders reflect current certification periods for all clients.
DPS will create In-Service and have education training with all Nursing Supervisors so they understand the process moving forward and obtain proper frequency orders
Administrator and DPS will audit all client charts weekly and review POC orders to ensure all will be updated for next certification period to ensure all clients have updated frequency orders by April 30, 2024.
Initial Comments:Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, Extended Family Care was found to be in compliance with the following requirements of 28 PA Code, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced State re-licensure and Medicare recertification survey completed on March 1, 2024, Extended Family Care was found to be in compliance with the following requirements of 28 PA Code, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
|