Commonwealth Home Health of Moses Taylor

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on review of agency policies and procedures, clinical records and personnel files, and based on interview with the administrator (Employee #11), the agency failed to ensure initial TB screening was performed in accordance with agency policy/procedure for five (5) of five (5) staff members whose date of hire was after December 3, 2021. (Employees #1, #5. #6, #7 and #10) Finding include: On December 6, 2024 at approximately 1:20 PM, review of agency policy 8.002, titled “Respiratory Protection Plan”, revealed the following under “Patient Care Settings”: Page 4: Upon hire, all staff having direct patient contact will undergo TB testing by...a two-step Tuberculin Skin Test (TST) and will complete the TB Risk Assessment... Page 5: Pennsylvania: For new hires, the TB Risk Assessment, TB Symptom Screening and TB test are required... Patient #3: On December 5, 2024 at approximately 9:08 AM, review of the clinical record revealed the physical therapist (PT-Employee #1) provided PT services in November and December 2024. Patient #7: On December 5, 2024 at approximately 11;55 AM, review of the clinical record revealed the licensed practical nurse (LPN-Employee #6) provided skilled nursing (SN) services in November 2024 and the registered nurse (RN-Employee #5) provided SN services in December 2024. Patient #10: On December 5, 2024 at approximately 2:17 PM, review of the clinical record revealed the home health aide (HHA-Employee #7) provided HHA services in November and December 2024. Patient #13: On December 5, 2024 at approximately3:52 PM, review of the clinical record revealed the RN (Employee #10) provided SN services in November and December 2024. On December 6, 2024 at approximately 10:43 AM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the PT was 06/03/2024. There was no documentation in the personnel file which provided evidence the PT completed a TB risk assessment nor TB symptom questionnaire upon hire. Employee #5: The date of hire of the RN was 06/19/2023. A single step TST was completed on 06/22/2023 but there was no documentation in the personnel file which provided evidence the RN completed the following upon hire: A second step TST, the TB risk assessment nor TB symptom questionnaire. Employee #6: The date of hire of the LPN was 11/16/2023. There was no documentation in the personnel file which provided evidence the LPN completed a TB risk assessment upon hire Employee #7: The date of hire of the HHA was 03/06/2024. There was no documentation in the personnel file which provided evidence the HHA completed a TB risk assessment nor TB symptom questionnaire upon hire. Employee #10: The date of hire of the contract RN was 08/05/2024. There was no documentation in the personnel file which provided evidence the HHA completed a TB risk assessment nor TB symptom questionnaire upon hire. During interview conducted on December 6, 2024 at approximately 2:05 PM, the administrator confirmed initial TB screening was not conducted in accordance with agency policy/procedure for the above referenced employees.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on review of agency policies and procedures and clinical records and based on interview with the administrator (Employee #11), the administrator failed to ensure a policy/procedure was developed to ensure skilled services provided via telehealth/telecommunications (routine phone visits) were completed in accordance with agency policy/procedure for four (4) of four (4) patients for whom telehealth/telecommunication services included completed interventions and/or resulted in a variance for the onsite visit frequency. (Patients #1, #2, #3 and #5) Finding include: On December 6, 2024 at approximately 1:45 PM, review of agency policy 5.005, titled “Organizational Responsibilities and Organizational Charts” revealed the following under “Procedure”: 4. The Executive Director (administrator)...assumes full legal authority and responsibility for the agency’s overall management and operation, provision of home health services.... Patient #1 (Discharge): Between December 3, 2024 at approximately 12:18 PM and December 6, 2024 at approximately 10:22 AM, review of the clinical record revealed the following orders were included on the “Home Health Certification and Plan of Care” for the initial certification period of 04/21/2024 through 06/19/2024: Skilled Nurse (SN)...may use telehealth and telecommunications to provide services as necessary and appropriate according to the patient’s condition and in accordance with the plan of care. Review of resumption of care (ROC) orders dated 04/28/2024 revealed SN services were to be provided as follows: Two (2) times a week for one (1) week followed by one (1) time a week for seven (7) weeks with two (2) prn (as needed) visits. Review of SN routine visit documentation revealed two (2) onsite SN visits were performed during the treatment week of 04/28/2024 through 05/04/2024 and that one (1) onsite SN visit was performed during the treatment weeks of 05/05/2024 through 05/11/2024 and 05/26/2024 through 06/01/2024 which were in accordance with the SN frequency orders included on the above referenced ROC order. Review of “Visit Note Report” documentation revealed SN routine phone visits were conducted by the licensed practical nurse (LPN-Employee #6) on 05/04, 05/10 and 05/30/2024 for a total of three (3) additional SN which exceeded the PRN SN visit frequency orders included under the ROC order. There was no documentation in the clinical record which provided evidence physician orders for the frequency of SN routine phone visits had been included on the above referenced ROC order nor was documentation present which provided evidence the RN was made aware of the need for SN routine phone visits prior to the routine phone visit conducted by the LPN on the above referenced dates. Patient #2 (Discharge): Between December 3, 2024 at approximately 1:33 PM and December 6, 2024 at approximately 10:24 AM, review of the clinical record revealed the following orders were included on the “Home Health Certification and Plan of Care” for the initial certification period of 06/21/2024 through 08/19/2024: Physical Therapy (PT) Visit Frequency: One (1) time a week for nine (9) weeks. PT...may use telehealth and telecommunications to provide services as necessary and appropriate according to the patient’s condition and in accordance with the plan of care. Review of PT routine visit documentation revealed one (1) onsite PT visit were performed during the treatment weeks of 06/23 through 06/29/2024, 06/30 through 07/06/2024 and 07/21 through 07/26/2024 which was in accordance with the PT visit frequency orders included on the above referenced “Home Health Certification and Plan of Care”. Review of “Visit Note Report” documentation revealed PT routine phone visits were conducted by the physical therapy assistant (PTA-Employee #8) on 06/25, 06/27, 06/28 and 07/01/2024 for a total of four (4) additional PT visits. PT interventions performed during the aforementioned routine phone visits included patient education There was no documentation in the clinical record which provided evidence physician orders for the frequency of PT routine phone visits had been included on the above referenced “Home Health Certification and Plan of Care” nor was documentation present which provided evidence the PT was made aware of the need for PT routine phone visits prior to the routine phone visits conducted by the PTA on the above referenced dates. Review of ROC orders dated 07/21/2024 revealed SN services were to be provided as follows: Two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks and two (2) prn visits. Review of SN routine visit documentation revealed one (1) of two (2) onsite SN visits were performed during the treatment week of 07/212024 through 07/27/2024 Review of “Visit Note Report” documentation revealed a SN routine phone visit was conducted by a RN on 07/22/2024. There was no documentation in the clinical record which provided evidence physician orders for the frequency of SN routine phone visits had been included on the ROC order. Patient #3: On December 5, 2024 at approximately 9:08 AM, review of the clinical record revealed the following orders were included on the “Home Health Certification and Plan of Care” for the initial certification period of 11/21/2024 through 01/19/2025: Physical Therapy (PT) Visit Frequency: One (1) time a week for nine (9) weeks. PT...may use telehealth and telecommunications to provide services as necessary and appropriate according to the patient’s condition and in accordance with the plan of care. Review of PT routine visit documentation revealed one (1) onsite PT visit was performed during the treatment week of 11/24 through 11/30/2024 which was in accordance with the PT visit frequency orders included on the above referenced “Home Health Certification and Plan of Care”. Review of “Visit Note Report” documentation revealed a PT routine phone visit was conducted by the PTA (Employee #8) on 11/29/2024. PT interventions performed during the aforementioned routine phone visit included patient education and assisting in the performance of the home exercise program. There was no documentation in the clinical record which provided evidence physician orders for the frequency of PT routine phone visits had been included on the above referenced “Home Health Certification and Plan of Care” nor was documentation present which provided evidence the PT was made aware of the need for PT routine phone visits prior to the routine phone visits conducted by the PTA on 11/29/2024. Patient #5: On December 5, 2024 at approximately 10:49 AM, review of the clinical record revealed the following orders were included on the “Home Health Certification and Plan of Care” for the initial certification period of 11/12/2024 through 01/10/2025: SN Visit Frequency: Two (2) time s a week for two (2) weeks followed by one (1) time a week for seven (7) weeks and two (2) PRN visits for wound complications. SN...may use telehealth and telecommunications to provide services as necessary and appropriate according to the patient’s condition and in accordance with the plan of care. Review of SN routine visit documentation revealed one (1) onsite SN visit was performed during the treatment weeks of 11/17 through 11/23/2024 and 11/24 through 11/30/2024 which was in accordance with the SN visit frequency orders included on the above referenced “Home Health Certification and Plan of Care”. Review of “Visit Note Report” documentation revealed SN routine phone visits were conducted by the RN (Employee #3) on 11/21, 11/22, 11/26 and 12/03/2024 for a total of four (4) additional SN visits which exceeded the PRN SN visit frequency orders included on the above referenced “Home Health Certification and Plan of Care. SN interventions performed during the aforementioned routine phone visit included patient education. There was no documentation in the clinical record which provided evidence physician orders for the frequency of SN routine phone visits had been included on the above referenced “Home Health Certification and Plan of Care”. During interview conducted on December 6, 2024 at approximately 2:05 PM, the administrator confirmed a policy regarding the provision of skilled services via telehealth/telecommunications (routine phone visits) had not been developed by the agency.”