Every finding on record at Advanced Nursing Care Inc

Based on the findings of an onsite unannounced Medicare recertification survey conducted October 24, 2023, through October 26, 2023, ANC Home Health Services, 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.

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted October 24, 2023, through October 26, 2023, ANC Home Health Services, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policy, and an interview with the administrator and director of nursing the agency failed to ensure physician orders were followed for five (5) of seven (7) clinical records reviewed (CR #2, 4, 5, 6, & 7) Findings include: Review of agency policy occurred on 10/26/23 at approximately 12:00 PM and revealed the following: Policy titled, "5.3. Patient Assessments/Plan of Care" states, "The care plan must specify the care, and services, necessary to meet the patient-specific needs, as identified in the comprehensive assessment, including the identification of the responsible discipline(s) and the measurable outcomes that the agency anticipates will occur. A physician's plan of treatment shall be dated, and signed, by the attending physician....and incorporated into the agency's permanent record for the patient, within 30 days... An RN, or physical therapist, will be assigned to each patient/client, as the case manager...A written plan of treatment, and orders, will be obtained from the admitting physician...The case manager, or designee, will make an initial home visit for the purpose of... Developing, and implementing, a nursing care plan, or physical therapy plan, with the patient/family, based on the initial assessment and the admitting physician's plan of treatment...Any changes in the physician's plan of treatment shall be made, in writing, and signed, timed, and dated by the physician, or (PA, ARNP, CNS as state allows), or by the registered nurse on the staff of the agency, pursuant to the verbal orders of the physician, which will be mailed to him for his signature and placed in the chart, within 7 days..." Policy titled, "1.9. Clinical Manager Responsibilities" states, "The clinical managers are responsible for the direction, coordination, and supervision of services. The clinical manager’s oversight must include the following...Ensuring that patient needs are continually assessed..." Registered Nurse Job Description States, "Responsibilities: Coordinates total patient care by conducting comprehensive health and psychological evaluation, monitoring the patient's condition...consult with the attending physician...submits clinical notes...and other clinical record forms outlining the services rendered as indicated...conducts and initial and ongoing comprehensive assessment of the patient needs...conducts a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc...develops and implements the nursing care plan...Provides skilled nursing care as outlined in the nursing care plan..." Review of Clinical records took place on 10/24/23 at approximately 12:30 PM and 10/25/23 at approximately 1:00PM and revealed the following: CR#2. State of Care: 9/27/23. Certification period reviewed: 9/28/23-11/26/23. On the Home Health Certification and Plan of Care (485) it contains an order for skilled nursing once weekly for one (1) week then two times weekly for eight (8) weeks. During the week of 9/28/23-9/30/23 two (2) skilled nurse visits were documented. In addition, on the skilled nurse visit that was conducted on 10/20/23 there were no vital signs documented by the skilled nurse. There was no documentation about physician notification regarding the change in visit frequency provided or any documentation of verbal orders obtained changing the skilled nursing frequency. CR#4. Start of Care: 9/19/22. Certification period reviewed: 7/16/23-9/13/23. On the Home Health Certification and Plan of Care (485) it contains an order for skilled nursing for 44 hours weekly shared with another agency. The Home Health Certification and Plan of Care for the certification periods 7/16/23-9/13/23 and 5/17/23-7/15/23 have not been signed by the physician. On the RN reassessment that was conducted on 7/11/23 the RN did not document any vital signs. There were no nursing visits conducted from 7/16/23 until 9/6/23. There was only a nursing note stating no skilled services due to lack of school but no physician order. There was no physician notification or verbal order stating no services related to school. CR#5. Start of Care: 9/22/23. Certification period reviewed: 9/24/23-11/22/23. On the Home Health Certification and Plan of Care (485) it contains an order for skilled nursing for two (2) visits per week for nine (9) weeks. On the skilled nurse visit that was conducted on 10/20/23 there were no vital signs documented by the skilled nurse. During the week of 9/24/23-9/30/23 there were three (3) skilled nurse visits documented. There was no documentation about physician notification regarding the change in visit frequency provided or any documentation of verbal orders obtained changing the skilled nursing frequency. CR#6. Start of Care: 8/31/23. Certification period reviewed: 9/1/23-10/30/23. On the Home Health Certification and Plan of Care (485) it contains an order for skilled nursing for seven (7) times per week for nine (9) weeks (daily visits). There were no nursing visits conducted from 9/2/23-9/12/23. Director of Nursing verbally stated on 10/25/23 at approximately 2:00 PM that the RN opened the case on 9/1/23 with the initial assessment but that another agency was providing care until 9/12/23. In addition, there were skilled nursing visits conducted on 9/25/23, 9/26/23, 9/27/23, 10/3/23 that were completely blank (no assessments, vital signs or narrative documented). On 10/2/23 and 10/10/23 there was incomplete documentation from the skilled nurse. On 10/2/23 there was no documentation of: pain, endocrine/hematologic, nutrition, labs, infection control, homebound status, plan of care review, discharge planning, care coordination, health management, interventions, response to care, medical necessity for care and visit narrative. On 10/10/23 there was only a narrative documented and no other assessments documented. In addition, the skilled nurse did not document any blood pressure measurements from 9/13/23 until 10/6/23. There was no documentation about physician notification regarding the change in visit frequency provided or any documentation of verbal orders obtained changing the skilled nursing frequency. CR#7. Start of Care: 9/1/23. Certification period reviewed: 9/1/23-10/30/23. On the Home Health Certification and Plan of Care (485) it contains an order for skilled nursing for two (2) hours three (3) times daily. The RN completed the initial assessment on 9/1/23 at 10:45 AM, there was a LPN visit conducted prior to the RN start of care on 9/1/23 at 5AM. An interview with the agency's administrator on 10/26/23 at approximately 2:00 pm confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical home visit (CHV) observations, a review of agency policies, and an interview with the administrator and director of nursing, the agency failed to follow its policy pertaining to infection control for one (1) of three (3) clinical home visits conducted, (CHV #3) Findings Include: A review of agency policy titled was conducted on 10/26/23 at approximately 12:00 PM and revealed the following: Policy titled, "7.2. Infection Control Program Requirements" states, "The agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases...Standard Precautions: Handwashing, Gloves...Standard Precautions shall be observed, by every healthcare worker, for all patients receiving care. Standard Precautions is a system of infection control developed, and based on, the degree of exposure, not diagnosis. Assume that blood and all body fluids, with or without visible blood, from all patients are potentially infectious. Therefore, the need to use personal protective equipment must focus on healthcare worker’s interaction with the patient’s blood, and/or body fluids, at the time of treatment or procedure, rather than on the diagnosis..." On-site clinical home visit was conducted on 10/25/23 at approximately 12:30PM. CHV #3, was conducted at approximately 12:30 PM at the home of CR #7. The skilled nurse performed intermittent catheterization (removing urine from the bladder by placing a tube in the bladder) with the use of gloves. When the nurse was done, she then cleaned the penis with soap and water and a towel without the use of any gloves as a protective barrier. The nurse then proceeded to place a condom catheter (a tube/collection device for urine that is place on the outside of the penis) on the patient without the use of any gloves to serve as a protective barrier. The nurse stated she places the condom catheter on this patient without gloves as it is "too hard to put on the condom catheter with gloves and they were wasting them." This observation revealed the nurse did not follow standard precautions as personal protective equipment (gloves) was not used as a barrier against infectious materials or any potential infectious disease exposure. An interview conducted with the administrator on 10/26/23 at approximately 2:00 pm confirmed the above findings.

Home health aide qualifications CFR(s): 484.80(a) Standard: Home health aide qualifications. This STANDARD is not met as evidenced by: Based on a review of personnel files (PF) and an interview with the administrator, the agency failed to demonstrate the following: A minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse for one (1) of eight (8) files reviewed: PF# 8 Findings include: A review of agency policy was conducted on 10/26/23 at approximately 12:00PM and revealed following: Policy titled, "4.3. Verification of Personnel Credentials" states, "All personnel qualifications must always be kept current... PA Specific: Home Health Aide Services: An individual with direct patient contact employed by the agency must meet at least one of the following requirements prior to referral to patients: A valid nurse's license in this Commonwealth, The successful completion of a nurse aide training program approved by the state of Pennsylvania, The successful completion of a home health aide training program as provided in 42 CFR 484.36 (relating to condition of participation: home health aide services) approved by the department...Verification of personnel Credentials...All personnel qualifications must always be kept current...The agency will ensure that all licensure information is current, at all times..." A review of personnel files (PF) was conducted on 10/25/23 at approximately 9:30 AM and revealed the following: PF#8. Date of Hire: 2/11/22. File revealed Home Health Aide (HHA) job description. File did not contain evidence of a minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. An interview conducted with the administrator on 10/26/23 at approximately 2:00 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of personnel files (PF), agency policies, and an interview with the director of nursing and administrator, personnel files at the agency failed to Complete/Document: A complete initial competency evaluation for three (3) of eight (8) PFs reviewed (PF# 1, 3, & 6) and An FBI Criminal Background Check for one (1) of eight (8) PFs reviewed (PF #2) and Child Abuse History Clearance for two (2) of eight (8) PFs reviewed (PF #1 & 3) and Complete Tuberculosis (TB) testing as required for one (1) of eight (8) PFs reviewed (PF #3) and Yearly competency evaluation for two (2) of eight (8) PFs reviewed (PF #3 & 6) and Have a current signed job description for one (1) of eight (8) PFs reviewed (PF #3) and Evidence of a minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse for one (1) of eight (8) PFs reviewed (PF#8) and Have a current version of a Physical Therapist's Pennsylvania License for one (1) of eight (8) PFs reviewed (PF#3). Findings include: A review of agency policy was conducted on 10/26/23 at approximately 12:00PM and revealed following: In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) Policy titled, "4.8. Background, Sex Offender and OIG Checks" states, "The agency should conduct criminal background checks for all employees, and contract staff, who have access to patients...The agency requires all applicants to submit with their applications, and requires all administrators and any operators who have or may have direct contact with a client to submit, the following information obtained within the preceding one-year period: Where the applicant is not, and for the two years immediately preceding the date of application has not been, a resident of Pennsylvania, the agency requires the applicant to submit with the application for employment a report of Federal criminal history record information. The applicant must submit a full set of fingerprints in a manner prescribed by the department...The state of Pennsylvania shall submit the fingerprints to the Federal Bureau of Investigation for a national criminal history record check..." Policy titled, "4.22. Skills Competency Evaluations" states, "Before any field staff member may conduct an unsupervised patient visit, he/she must pass a skills competency evaluation. Skills competency evaluation are, next, conducted on the one-year anniversary of employment and then, annually, thereafter..." Policy titled, "4.4 TB Testing/Screening " states, "Prior to patient contact, direct care personnel provide or have: Upon hire personnel provide evidence of a baseline TB skin or blood test. Prior to patient contact, an individual TB risk assessment and symptom evaluation are completed to determine if high risk exposures have occurred since administration of the baseline TB test. If there is no evidence of a baseline TB skin or blood test, TB testing is conducted by the organization..." Policy titled, "4.6. Job Descriptions" states, "Each agency employee will have a signed job description for each position within the agency, at time of hire, annually, and whenever the job description changes, as needed. " Policy titled, "4.3. Verification of Personnel Credentials" states, "All personnel qualifications must always be kept current... PA Specific: Home Health Aide Services: An individual with direct patient contact employed by the agency must meet at least one of the following requirements prior to referral to patients: A valid nurse's license in this Commonwealth, The successful completion of a nurse aide training program approved by the state of Pennsylvania, The successful completion of a home health aide training program as provided in 42 CFR 484.36 (relating to condition of participation: home health aide services) approved by the department...Verification of personnel Credentials...All personnel qualifications must always be kept current...The agency will ensure that all licensure information is current, at all times..." A review of Department of Human Services Website KeepKidsSafe.pa.gov revealed a document titled, "Employees Having Contact with Children" which states, "Employees having contact with children must obtain the following three clearances: Report of criminal history from the Pennsylvania State Police (PSP), Child Abuse History Clearance from the Department of Human Services (Child Abuse) and Fingerprint-based federal criminal history submitted through the Pennsylvania State Police or its authorized agent (FBI)..." A review of personnel files (PF) was conducted on 10/25/23 at approximately 12:00 PM and revealed the following: PF#1. Date of Hire: 8/23/23. File did not contain any documentation of initial RN competency completed. In addition, file did not contain a Child Abuse History Clearance (agency with pediatric skilled patients). PF#2. Date of Hire: 3/3/16. File contained Delaware State Driver's License that was issued on 7/10/14. File did not contain FBI Criminal Background Check. PF#3. Date of Hire: 4/30/21. File review revealed Physical Therapist License that expires on 12/31/22. File did not contain an updated Physical Therapy license. Surveyor Reviewed the Pennsylvania state website immediately on 10/25/23 at approximately 12:30 PM and revealed their license as current (expires 12/31/24). File revealed a signed job description for a "Physical Therapy Assistant" but not a current job description for "Physical Therapist." File did not contain any documentation for an initial skilled competency evaluation. File did not contain any yearly skills evaluations for 2022 or 2023. File did not contain any documentation of TB testing. In addition, file did not contain a Child Abuse History Clearance (agency with pediatric skilled patients). PF#6. Date of Hire: 10/15/21. File revealed Licensed Practical Nurse (LPN) job description. File did not contain any documentation of initial skills competency completed. File did not contain any yearly skills evaluations for 2022 or 2023. PF#8. Date of Hire: 2/11/22. File revealed Home Health Aide (HHA) job description. File did not contain evidence of a minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. An interview conducted with the administrator on 10/26/23 at approximately 2:00 PM confirmed the above findings.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on review of employee personnel (PF) files, and an interview with agency staff, the governing body and the administrator failed to ensure a supervising registered nurse or similarly qualified alternate, is available at all times during operating hours. Findings included: A review of personnel files conducted on 10/25/23 at approximately 12:00PM revealed the following: PF #1, date of hire 8/23/23. The PF contained a job description for the "Alternate Clinical and QA (Quality Assurance) Manager." A review of Governing Body minutes from 10/4/23 was conducted on 10/24/23 at approximately 1:00 PM and listed PF#1 as the interim Director of Nursing. A review of the agency organizational chart on 10/24/23 at approximately 12:00PM listed no alternate director of nursing identified. In an interview with the administrator and alternate administrator on 10/26/23 at approximately 2:00 P.M., PF#1 was identified as the interim Director of Nursing. There was no alternate director of nursing identified. The administrator stated that the agency is actively recruiting for the director of nursing position and then PF#1 would become the alternate Director of Nursing.