QA Investigation Results

Pennsylvania Department of Health
CENTERWELL HOME HEALTH
Health Inspection Results
CENTERWELL HOME HEALTH
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an unannounced onsite Medicare recertification survey completed December 5, 2022, Centerwell Home Health 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 Medicare recertification survey completed December 5, 2022, Centerwell Home Health 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:




484.105(b)(2) ELEMENT
Ensures qualified pre-designated person

Name - Component - 00
When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section.

Observations: Based on a review of agency policy and an interview with the agency Administrator, the agency failed to ensure a qualified, pre-designated person was approved by the Governing Body to act in the absence of the administrator for one (1) of one (1) interviews (Interview #1). Findings Include: Agency policy/procedure was reviewed on December 5, 2022 at approximately 9:30 a.m. Policy #02-16 'Administration' states "Responsibility for administration, ....is vested in the Administrator appointed by the representative of the Governing Body and/or by the Governing Body." "The Administrator of the Home Health Agency will be a: ......... In the absence of the Administrator a qualified person is designated in writing to assume responsibility for the office operations." Interview #1: Interview was conducted with the Administrator on December 30, 2022 at approximately 11:00 a.m. The Administrator was asked who the agency alternate Administrator is. She stated "(EF#11)." No documentation of (EF#11) being pre-designated to act as the agency alternate Administrator. Documentation provided of "Resolution Governing Body' dated December 6, 2021 and signed by the Governing Body Secretary of (EF#11) being appointed/approved as the alternate Administrator, ........, effective "5/22/2020." Documentation provided of the 'Minutes of the Governing Body Meeting' dated December 13, 2021 appointing (EF#11) as the alternate Administrator. An interview conducted with the agency Administrator on December 5, 2022 at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

484.105(b)(2) Ensures qualified pre-designated person
Plan of Correction
Education:
1) A Governing Body member/ Designee will provide 1:1 education to the Administrator on Centerwell Home Health Policy 2-16 and FRC 484.105(b)(2) which indicates that the alternate administrator appointment will be authorized in writing prior to the commencement of duties for responsibility of office operations by the Governing Body and Administrator.
Monitor:
1) The Administrator will verify the letter of appointment has been received and authorized PRIOR for any change in alternate administrator designee.



Initial Comments:

Based on the findings of an unannounced onsite state re-licensure survey completed December 5, 2022, Centerwell Home Health 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

Name - Component - 00
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 Administrator, the agency failed to ensure a written summary report for each patient was sent to the attending physician at least every 60 days for seven (7) of eight (8) recertification clinical records (CR) reviewed (CR#1, CR#3, CR#5, CR#10, CR#16 - CR#18). Findings: Agency policy/procedure was reviewed on December 5, 2022 at approximately 9:30 a.m. Policy '03-16 Coordination of Care - Case Conferences' 'Case Communication' states "The clinical Manager or designee will send a written summary of the Plan of Care to the physician/allowed practitioner at least every 60 days for all patients." A review of CRs was completed on December 5, 2022 at approximately 11:30 a.m. The patients start of care (SOC) is listed below. CR#1 SOC 09/06/22: Patients most recent recertification period 11/05/22 - 01/03/23. Patients 'Home Health Certification and Plan of Care' for the period of 09/06/22-11/04/22 was reviewed. Documentation provided of a written summary being sent to the physician on 11/07/22. (63 days). CR#3 SOC 09/07/22: Patients most recent recertification period 11/06/22 - 01/04/23. Patients 'Home Health Certification and Plan of Care' for the period of 09/07/22-11/05/22 was reviewed. Documentation provided of a written summary being sent to the physician on 11/07/22. (62 days). CR#5 SOC 09/28/22: Patients most recent recertification period 11/27/22 - 01/25/23. Patients 'Home Health Certification and Plan of Care' for the period of 09/28/22-11/26/22 was reviewed. Documentation provided of a written summary being sent to the physician on 11/28/22. (62 days). CR#10 SOC 04/26/22: Patients most recent recertification period 10/23/22 - 12/21/22. Patients 'Home Health Certification and Plan of Care' for the period of 04/26/22-06/24/22 was reviewed. Documentation provided of a written summary being sent to the physician on 06/27/22. (63 days). CR#16 SOC 07/20/22: Patients most recent recertification period 09/18/22 - 11/16/22. Patients 'Home Health Certification and Plan of Care' for the period of 07/20/22-09/17/22 was reviewed. Documentation provided of a written summary being sent to the physician on 09/19/22. (62 days). CR#17 SOC 05/26/22: Patients most recent recertification period 09/23/22 - 11/21/22. Patients 'Home Health Certification and Plan of Care' for the period of 05/26/22-07/24/22 was reviewed. Documentation provided of a written summary being sent to the physician on 07/25/22. (61 days). CR#18 SOC 08/26/22: Patients most recent recertification period 10/25/22 - 12/23/22. Patients 'Home Health Certification and Plan of Care' for the period of 08/26/22-10/24/22 was reviewed. Documentation provided of a written summary being sent to the physician on 10/25/22. (61 days). An interview conducted with the agency Administrator on December 5, 2022 at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

60 day summaries being sent at least every 60 days 601.21
Plan Of Correction
60 day summaries being sent at least every 60 days 601.21
Corrective Action:
Education:
1) The Administrator or designee will provide 1:1 education to all clinicians involved in the care of survey patient's #1,#3,#5,#10,#16,#18 of the need for a written summary to be sent to MD at least every sixty days per PA 601.21(h)
2) The Administrator or designee will provide education to all administrative staff and clinical staff the need for a written summary to be sent to MD at least every sixty days per PA 601.21 (h)
Monitor:
1)The administrator or designee will monitor 25 Recertification periods to ensure written summary is provided to MD at least every 60 days x weekly for 4 weeks. Then 20 a month for 3 months or until 100% compliance is obtained. The results will be incorporated into QAPI x 2 quarters and reported to the governing body



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 a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to obtain a physician signature on verbal orders within seven (7) days on two (2) of eighteen (18) clinical records (CR) reviewed (CR#12, CR#17).

Findings include:

Agency policy/procedure was reviewed on December 5, 2022 at approximately 9:30 a.m. Policy #PA 3-12-7.0 'Physicians Orders' 'Instead of Company Policy' section (3) states "Verbal orders will be countersigned by the physician within 7 days."
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 completed on December 5, 2022 at approximately 11:30 a.m. The patients start of care (SOC) is listed below.
CR#12 SOC 10/28/22: Verbal physician's order taken by a registered nurse (RN) on 10/27/2022 for the certification period 10/28/22-12/26/22. The physician's countersignature was obtained on 12/02/22. (36 days.)
CR#17 SOC 05/26/22: Verbal physician's order taken by a registered nurse (RN) on 05/26/2022 for certification period 05/26/22-07/24/22. The physician's countersignature was obtained on 07/14/22. (49 days.)

An interview conducted with the agency Administrator on December 5, 2022 at approximately 11:45 a.m. confirmed the above findings.











Plan of Correction:


Conformance with Physician Orders 601.31
Plan of Correction
Corrective Action:
Education:
1)The Administrator or designee will provide 1:1 education to all clinicians involved in the care of survey patients #12, #18 of the requirements for all verbal orders to be recorded, signed and obtainment of the physician counter signature within 7 days per PA 601.31(d)
2)The Administrator or designee will provide education to all clinicians and administrative staff on the requirements for all oral orders to be recorded, signed and obtainment of physician counter signature within 7 days per PA 601,31 (d)
Monitor:

1)The Administrator or designee will monitor 75 add -on verbal orders weekly to ensure all requirements are met per PA 601.31 (d) x 8 weeks or 100% compliance is obtained
2)Then ongoing compliance will be reviewed during quarterly qapi review x 2 quarters, The results will be incorporated into QAPI x 2 quarters and reported to Governing Body



Initial Comments:

Based on the findings of an unannounced onsite state re-licensure survey completed December 5, 2022, Centerwell Home Health 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 December 5, 2022, Centerwell Home Health was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).








Plan of Correction: