Hospital Home Care Services

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Per the following Memorandums issued by the Pennsylvania DEPARTMENT OF STATE: “ April 13, 2020, Pennsylvania Changes Supervision Requirements for Physical Therapists, Occupational Therapists, Speech Language Pathologists and Audiologists During Covid-19 Emergency ... To increase patient and practitioner safety and decrease exposure to the virus, the Department of State requested, and the Governor approved, temporary suspension of all statutory and regulatory requirements for licensees ... that call for direct supervision, or require contact/interaction that is ’ in-person, “ “ face-to-face, “ “ onsite, “ “ on the premises “ or the like ... These temporary suspensions shall last for the duration of the COVID-19 emergency unless rescinded sooner or extended by the Governor or the Department. “ “ May 4, 2022, COVID-19 REGULATORY SUSPENSIONS AND WAIVERS THAT WILL EXPIRE ON ... JUNE 20, 2022 ... Supervision Requirements for Physical Therapists ... This waiver suspended all statutory and regulatory requirements for licensees ... that call for direct supervision or require contact/interaction that is “ in-person, “ ’ face-to-face, “ “ on-site, “ “ on the premises “ or the like. “ Home Health Agency Conditions of Participation... January 2018 “The HIPAA Privacy Rule Sets national standards for covered entities (... health care providers that conduct certain health care transactions electronically)... including appropriate safeguards to protect the privacy of protected health information (PHI)... The Security Rule specifies safeguards that covered entities and their business associates must implement to protect the confidentiality, integrity, and availability of electronic protected health information (PHI).” Based on review of Memorandums issued by the Pennsylvania DEPARTMENT OF STATE, Home Health Conditions of Participation, Clinical Records (CR) and staff (EMP) interviews, the agency provided Physical Therapy Services via Telehealth after the expiration date of June 20, 2022 for the temporary suspension of Home Health Services that “require contact/interaction that is “ in-person, “ ’ face-to-face, “ “ on-site, “ “ on the premises “ or the like “ and did not provide appropriate safeguards to protect the privacy of protected health information (PHI), for two (2) of nine (9) CR of Patients who received Home Health Physical Therapy (CR1 & CR2). Findings included: A Review of CR was conducted on 3/21/2022 from approximately 8:30 a.m. to 3:30 p.m. Review of CR1, SOC 2/12/2024, on 3/18/2024 from approximately 10:00 a.m. to 11:00 a.m. revealed the following: “ HOME HEALTH CERTIFICATION AND PLAN OF CARE ... Certification Period From: 2-12-2024 To: 4-11-2024 ... Principal Diagnosis Aftercare following joint replacement ... Orders for Discipline and Treatments ... Physical Therapy 2/12/24 - 2/16/2024 - 1 Within Five Days for 5 Days PHYSICAL THERAPY ASSISTANT: (Effective: 2/13/24) 02/14/24 - 02/24/24 - 2 Every Week for 1 Week; 3 Every Week for 1 Week. “ The following Home Health Physical Therapy Admission Visit note revealed: “ Start Date/Time: 02/12/24 02:30 End Date/Time:02/12/24 03:30 ... Clinician: (PF6) PT ... Visit Type HH PT Admit Visit ... Method: Who: Patient ... How: This evaluation was completed via synchronous telehealth visit with PTA as extender, with patient permission. Real time audio-video was utilized, and measures were taken to ensure patient privacy and adherence to HIPAA requirements. “ Review of CR2, SOC 2/14/2024, on 3/18/2024 from approximately 11:00 a.m. to 12:00 p.m. revealed the following: “ HOME HEALTH CERTIFICATION AND PLAN OF CARE ... Certification Period From: 2-14-2024 To: 4-13-2024 ... Principal Diagnosis Aftercare following joint replacement ... Orders for Discipline and Treatments ... Physical Therapy 2/14/24 - 2/15/2024 - 1 Within Two Days for 2 Days PHYSICAL THERAPY ASSISTANT: 02/16/24 - 02/24/24 - 1 Every Week for 1 Week; 3 Every Week for 1 Week. “ The following Home Health Physical Therapy Admission Visit note revealed: “ Start Date/Time: 02/14/24 09:00 End Date/Time: 02/14/24 10:00 ... Clinician: (PF6) PT ... Visit Type HH PT Eval Visit ... Method: Who: Patient ... How: This evaluation was completed via synchronous telehealth visit with PTA as extender, with patient permission. Real time audio-video was utilized, and measures were taken to ensure patient privacy and adherence to HIPAA requirements. “ An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. confirmed the above findings. Surveyor Asked “What Real time audio-video was utilized for the telehealth visits?” Agency Administrator answered “Cell Phones”. Surveyor asked “Were the cell phones utilized for telehealth owned by the Agency and issued to Clinicians for the specific purpose of conducting Agency business?” Agency Administrator Answered, “No, Clinicians utilize their own personal cell phones and are given a stipend as reimbursement for usage for Agency business,” Surveyor then asked to see the “Cell Phone Policy,” and the Agency Administrator replied, “We do not have one.” When asked “What measures were taken to ensure patient privacy and adherence to HIPAA requirements?” Agency Clinical Manager answered “There is a HIPAA compliant app that is used for texting and written communication.” Surveyor asked “How was the video portion of the telehealth visit protected?” Agency Clinical Director answered “I guess the video portion of the telehealth visit was not HIPAA compliant regarding privacy. A designated portal was not utilized for the transfer of video information between the PT and PTA.””

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on a review of clinical records (CR), and an interview with the agency staff, agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge for five (5) of five (5) discharged clinical records reviewed (CR1 - CR5). Findings included: A Review of CR was conducted on 3/21/2024 from approximately 8:30 a.m. to 3:30 p.m. Review of CR1, SOC 2/12/2024, certification period 2/12/2024 to 4/11/2024 revealed patient was discharged 2/23/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR2, SOC 2/14/2024, certification period 2/14/2024 to 4/13/2024 revealed patient was discharged 2/26/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR3, SOC 2/21/2024, certification period 2/21/2024 to 4/20/2024 revealed patient was discharged 2/30/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR4, SOC 2/08/2024, certification period 2/08/2024 to 4/07/2024 revealed patient was discharged 3/07/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. Review of CR5, SOC 2/21/2024, certification period 2/21/2024 to 4/20/2024 revealed patient was discharged 2/26/2024. There was no documentation in CR to indicate that a discharge summary was ever completed or forwarded to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge. An interview with Agency Administrator, Clinical Manager and Hospital Compliance Representative on 3/22/2024 at approximately 2:00 p.m. confirmed the above findings.”