Every finding on record at Prospect Crozer Home Health and Hospice, LLC

Based on the findings of an unannounced onsite Medicare home health agency complaint investigation conducted June 7, 2022, June 15, 2022, and concluded on June 17, 2022, Crozer Keystone Home Health 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.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and interview with agency staff it was determined the agency failed to ensure the registered nurse (RN) documented wound measurements according to agency policy for one (1) of three (3) CR reviewed. (CR #1) Findings Included: A review of agency policy titled “Wound Care” on June 16, 2022, at approximately 8:00 A.M. stated, “Documentation Standards: A. All wounds will be measured/staged at the start of care and one time each calendar week. Measurements include length, width, depth and location.” A review of clinical records conducted on June 7, 2022, from approximately 12:30 P.M. to 3:30 P.M. and June 14, 2022, from 12:00 P.M. to 4:00 P.M. revealed the following: CR #1, start of care March 31, 2022, certification period reviewed March 31, 2022, through May 29, 2022. Diagnosis: unspecified open wound of right lower leg, subsequent encounter. Patient was discharged to the hospital on May 9, 2022. Orders for care included skilled nursing assess and evaluate one (1) visit per week for one (1) week from March 30, 2022, through April 4, 2022. Effective April 3, 2022, skilled nursing visits (SNV) two (2) times per week for four (4) weeks, and four (4) PRN (as needed). Home health aide (HHA) visits beginning week of April 3, 2022, one (1) visit per week for four (4) weeks. SNV’s were completed on March 31, 2022, April 3, 6, 15, 20, 27, and 29, 2022, and May 4, 5, 6, and 10, 2022. Missed visits were documented on April 1 and 12, 2022, due to wound center visits. A missed visit was documented on April 22, 2022, with no reason documented. There were no wound measurements documented on the initial assessment visit on March 31, 2022, due to the wound covered with a non-removable dressing. Wound measurements were documented on April 20, 2022, and May 4, 5, 6, and 9, 2022. Wound care was documented on April 3, 6, 15, 20, 27, 29, 2022, and May 4, 5, 6, and 10, 2022. An interview with agency staff was conducted on June 7, 2022, at approximately 4:00 P.M. Present were the agency director, the quality improvement manager, and the clinical manager. A follow-up email with the agency administrator on June 17, 2022, confirmed the above findings.

Based on the findings of an onsite unannounced Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone Home Health Agency 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 Medicare recertification and state re-licensure survey conducted May 11, 2021 through May 13, 2021, and off-site on May 14, 2021 and May 17, 2021, Crozer Keystone Home Health Agency 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.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on review of agency ' s policies and procedures, clinical records (CR), and interview with the agency staff, it was determined that the agency failed to ensure physician ' s orders were followed for Occupational Therapy assessment and evaluation for one (1) of seventeen (17) clinical records (CR) reviewed (CR #11). Findings include: Review of agency policy titled "Assessment Documentation - Section 2.5", on May17, 2021 at approximately 9:45AM, policy states, " ....After the initial assessment, referred disciplines will complete discipline specific assessments within seven (7) days ....D. Confirmed missed visits: Missed visit reasons will be documented under visit management, and the MD or designee will be notified .... " A review of clinical records conducted on May 11, 2021, at approximately 2:10PM and May 12, 2021 at approximately 10:15AM, revealed the following: CR #11, start of care 2/14/2021. Certification period 2/14/2021 through 4/14/2021 - Contained orders for Occupational Therapy (OT) (2/8/2021 - 2/22/2021): Assess and Evaluation. Review of the OT visit documentation on 5/11/2021 at approximately 3:00PM and 5/12/2021 at approximately 10:45AM, revealed an initial evaluation was scheduled for 2/22/2021. However, this visit was missed, and no subsequent visit was scheduled thereafter. There was no documentation that physician was notified that the initial OT evaluation was not made. Interview with alternate administrator on 5/12/2021 at approximately 11:00AM, alternate administrator stated, that shortly after 2/22/2021, CR #11 was hospitalized, and upon her hospital discharge, CR #11 only received orders for SN. CR #11 was discharged from agency on 4/12/2021. Interview with administrator on 5/13/2021 at 1:30PM confirmed the above findings.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on review of agency ' s policies and procedures, clinical records (CR), and interview with the agency staff, it was determined that the agency failed to follow its procedure to ensure physician was notified of missed visits and that missed visits were documented in clinical record for two (2) of seventeen (17) clinical records (CR) reviewed (CR #3 and #11). Findings include: Review of agency policy titled "Assessment Documentation - Section 2.5", on May17, 2021 at approximately 9:45AM, policy states, " ....After the initial assessment, referred disciplines will complete discipline specific assessments within seven (7) days ....D. Confirmed missed visits: Missed visit reasons will be documented under visit management, and the MD or designee will be notified .... " A review of clinical records conducted on May 11, 2021, at approximately 2:10PM and May 12, 2021 at approximately 10:15AM, revealed the following: CR #3, start of care 3/21/2021. Certification period 3/21/2021 through 5/19/2021 - Contained orders for Home Health Aide (HHA) (3/28/2021 - 5/15/2021): One (1) HHA visit per week for seven (7) weeks. Review of the HHA visit documentation on 5/11/2021 at approximately 2:10PM and 5/12/2021 at approximately 10:20AM, revealed a missed visit on 4/6/2021. There was no documentation that physician was notified of missed visit. CR #11, start of care 2/14/2021. Certification period 2/14/2021 through 4/14/2021 - Contained orders for Occupational Therapy (OT) (2/8/2021 - 2/22/2021): Assess and Evaluation. Review of the OT visit documentation on 5/11/2021 at approximately 3:00PM and 5/12/2021 at approximately 10:45AM, revealed an initial evaluation was scheduled for 2/22/2021. However, this visit was missed, and no subsequent visit was scheduled thereafter. There was no documentation that physician was notified that the initial OT evaluation was not made. Interview with administrator on 5/13/2021 at 1:30PM confirmed the above findings.