Ahc Home Health and Hospice of Lehigh Valley

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of agency policy, a review of the clinical record, and an interview with the agency Administrator, the agency failed to ensure visits or a treatment or service as required by the plan of care was conducted as ordered for one (1) of one (1) clinical records (CR) reviewed (CR#1). Agency policy/procedure reviewed on December 23, 2024 at approximately 12:00 p.m. Policy ‘Missed Visits’ ‘Procedure’ section (2) states “If a visit is missed and not rescheduled the clinician will: (A) Notify the physician and clinical supervisor of the missed visit and the reason for the missed visit.” A review of CRs was conducted on December 23, 2024 at approximately 11:30 a.m. The patients start of care (SOC) is listed below. CR#1 SOC 09/10/24: Patients certification of the Plan of Care for the period of 11/09/24 - 01/07/24 reviewed. ‘Orders/Treatments’ include but is not limited to orders for a physical therapist (1week3: PT maintenance beginning during week of 11/15/24 - Ending on 11/30/24). The week of 11/10/24-11/16/24 physical therapy conducted 0/1 visits. No documentation provided of the agency notifying the physician of the missed visit. An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.”

“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 a review of agency policy, a review of employee files, and an interview with the agency Administrator, the agency failed to ensure tuberculosis (TB) screening was conducted upon hire, per policy, for two (2) out of five (5) employee files (EF) reviewed (EF#1, EF#3). Policy ‘Categories/Qualifications of Personnel/ ‘Health Requirements’ section (1) states “Personnel with Patient Contact: ..... personnel must have a TST (tuberculin skin test) or show evidence that there is no active Tuberculosis in the past 12 months (by providing a copy of a negative TST taken within the past 12 months) prior to providing care. Documentation of these tests will be maintained in the personnel health file.” (Note: This policy is not in accordance with CDC TB testing recommendations, which include, but is not limited to, utilizing the two-step TST method.) A review of EFs was conducted on December 23, 2024 at approximately 10:00 a.m. The employees date of hire (DOH) is listed below. EF#1 DOH 08/27/24: No documentation of TB testing upon hire. EF#3 DOH 09/23/24: No documentation of TB testing upon hire. An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on a review of agency policy, a review of the patient admission handbook, and an interview with the agency Administrator, the agency failed to ensure the patient was advised of the state toll free home health telephone hot line (1-800-254-5164), its contact information, its hours of operation, and that its purpose is to receive complaints or questions about home health agencies for one (1) of one (1) patient admission handbooks reviewed (Patient Handbook #1). Agency policy/procedure reviewed on December 23, 2024 at approximately 12:00 p.m. Policy ‘Patient Bill of Rights’ ‘Procedure’ section (L) states “Receive in writing, prior to the start of care, the telephone numbers for the State Home Health Hotline ..., including hours of operation, and the purpose of the hotline/s to receive complaints or questions about the organization. ...” A review of the patient admission handbook was conducted on December 23, 2024 at approximately 11:00 a.m. revealed the following: Patient Handbook #1: The ‘Patient Handbook’ page #9 states “.... ‘State Hotline’ (wrong phone number listed). ...” Page #13 states “To file a complaint to the State by calling their hotline. ....(wrong number listed). An interview conducted with agency Administrator on December 23, 2024 at approximately 1:00 p.m. confirmed the above findings.”