Every finding on record at Scranton Quincy Home Care Services, LLC

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on December 3, 4 and 6, 2024, with the off-site portion of the survey being conducted on December 5, 2024, Commonwealth Home Health of Moses Taylor 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 unannounced, onsite Medicare recertification survey conducted on December 3, 4 and 6, 2024, with the off-site portion of the survey being conducted on December 5, 2024, Commonwealth Home Health of Moses Taylor was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted November 30, 2021 through December 3, 2021, Commonwealth Home Health of Moses Taylor was determined 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 unannounced, onsite Medicare recertification survey conducted November 30, 2021 through December 3, 2021, Commonwealth Home Health of Moses Taylor was determined not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The Medicare recertification survey was conducted at the Scranton parent office on November 30, December 1 and December 3, 2021 and at the Tunkhannock branch office on December 2, 2021.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation and the Pennsylvania (PA) Department of Health (DOH) Event Reporting System (ERS) website reports, and based on interview with the administrator, the agency failed to submit two (2) of nine (9) COVID-19 related Health Department Reportable Diseases reports to the PA DOH ERS website. (Employees #2 and #3) Findings included: On November 30, 2021 at approximately 2:15 PM, review of agency policy titled "LHC Group COVID-19 Plan-Home Health and Hospice" revealed the following: Purpose and Scope...LHC Group is committed to providing a safe and healthy workplace for all employees.... Recordkeeping...Risk Management will establish a COVID-19 log to record each instance in which an employee is COVID-19 positive... On November 30, 2021 at approximately 2:17 PM, review of agency document titled "DOH Provides Update for Reporting COVID-19 Cases", which was attached to the binder titled COVID-19, revealed the following: Agencies are no longer required to report the cases through the 1-877-PAHEALTH contact line just the through the (PA DOH) ERS system (website). Review of the agency staff list and the COVID-19 binder on November 30, 2021 at approximately 1:27 PM revealed the following: Employee #2: The date of hire of the occupational therapist (OT) was 12/14/2009. Review of COVID-19 testing results revealed the OT tested positive for COVID-19 on 11/19/2020. Employee #3: The date of hire of the registered nurse (RN) case manager was 09/08/2020. Review of medical report documentation included in the COVID-19 binder revealed the RN tested positive for COVID-19 on 11/19/2020. On November 30, 2021 at approximately 3:40 PM, review of the PA DOH ERS website revealed the agency last submitted a report of COVID-19 positive cases to the PA DOH ERS website on June 8, 2020. There was no documentation on the PA DOH ERS website which provided evidence that the agency had submitted a report of the above referenced COVID-19 positive cases to the PA DOH ERS website. During interview conducted on December 3, 2021 at approximately 2:20 PM, the administrator confirmed the agency failed to submit the above referenced COVID-19 reports to the PA DOH ERS website.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, clinical records, and CMS (Centers for Medicare/Medicaid Services) wound assessment guidelines, and based on interview with the administrator, the agency failed to ensure the progress toward wound healing goals were assessed by the supervising clinician/registered nurse (RN) for three (3) of six (6) patients for whom non-surgical wound care orders/goals were included on the "Home Health Certification and Plan of Care". (Patients #9, #14 and #15) Findings include: On December 3, 2021 at approximately 2:13 PM, review of the agency policy titled "Wound Assessment, Documentation, and Photography" revealed the following: Policy...Unless otherwise ordered by the physician, the registered nurse or physical therapist will assess wounds at least... -Weekly for patients receiving....having an infected wound, or have stage IV pressure injury with evidence of infection or exposed bone, tendon or muscle tissue. -Every other week for patients receiving wound care by the agency at a frequency less than daily... Reassessments will be documented on the wound assessment tool. The assessment includes measurement of length, width, and depth, undermining, and tunneling... On December 3, 2021 at approximately 4:50 PM, review of the CMS (Centers for Medicare/Medicaid Services) website () revealed the following: Medicare coverage for wound care on a continuing basis, for a given wound, in a given patient, is contingent upon evidence documented in the patient's medical record that the wound is improving in response to the wound care being provided. Evidence of improvement may include measurable changes in the following... Wound dimensions (surface measurements, depth) Granulation tissue Necrotic tissue/slough Tunneling or undermining Patient #9: On December 2, 2021 at approximately 1:31 PM, review of the clinical record revealed the start of care date was 03/12/2021, the primary diagnosis was pressure ulcer (wound) of the sacral region (bottom of spine) stage 4 (pressure wound which extended into the muscle and/supporting structures such as the tendons) and that the following was included on the "Home Care Certification and Plan of Care" for the initial certification period of 03/12/2021 through 05/10/2021: -Skilled nurse (SN) visit frequency two (2) times a week for one (1) week, followed by three (3) times a week for two (2) weeks, then two (2) times a week for one (1) week, then one (1) time a week for six (6) weeks with two (2) prn (as needed visits). -SN to perform/instruct caregiver procedure of wound care to the stage 4 sacral pressure ulcer daily. -Goals: -Changes in wound status will be identified and reported to the physician for prompt intervention to minimize associated risks. -Caregiver will demonstrate improved wound status by decreased size, drainage, no signs/symptoms of infection, decreased pain as a result of skilled intervention within 8 weeks. Review of "Wound Record Report" documentation revealed the following: 03/25/2021: The stage 4 sacral pressure ulcer measured 2.4 centimeters (cm) in length by 0.7 cm in width by 2.3 cm in depth and that a large amount of purulent exudate (wound drainage which may indicate infection was present). Wound care was provided by the registered nurse (RN-employee #12). 03/29/2021: Wound care was provided by the RN (employee #12 and a large amount of purulent wound drainage was present. 04/05/2021: The stage 4 sacral pressure ulcer measured 2.0 cm by 0.6 cm by 2.5 cm. Wound care was provided by the RN (employee #12). There was no documentation on the "Wound Record Report" which provided evidence that the RN measured the stage 4 sacral pressure ulcer during the SN visit performed on 03/29/2021. Patient #14: On December 3, 2021 at approximately 7:55 AM, review of the clinical record revealed the start of care date was 11/112021, the primary diagnosis was urinary tract infection and that the following was included on the "Home Care Certification and Plan of Care" for the initial certification period of 11/11/2021 through 01/09/2022: -SN visit frequency one (1) times a week for one (1) week, followed by two (2) times a week for two (2) weeks, then one (1) time a week for two (2) weeks, then two (2) times a week for one (1) week, followed by one (1) time a week for three (3) weeks with two (2) prn visits for wound issues. -SN to perform/instruct caregiver procedure of wound care to the stage 2 (shallow, open wound) buttock pressure ulcer every 3 to 5 days and as needed. -Goals: -Patient/Caregiver will demonstrate improved wound status by decreased size, drainage, no signs/symptoms of infection, decreased pain as a result of skilled intervention within 8 weeks. Review of "Wound Record Report" documentation revealed the RN (employee #3) measured the left lower buttock wound and described the wound appearance as being necrotic during the start of care visit performed on 11/11/2021 but there was no documentation which provided evidence that the RN measured the right lower buttock wound which was identified as stage 2 during the start of care SN visit performed on 11/11/2021. Patient #15: On December 3, 2021 at approximately 12:05 PM, review of the clinical record revealed the start of care date was 03/03/2021, the primary diagnosis was diverticulitis of the intestine and that the following was included on the "Home Care Certification and Plan of Care" for the recertification period of 05/02/2021 through 06/30/2021: -Skilled nurse (SN) visit frequency one (1) time a week for one (1) week followed by one (1) time a week for three (3) weeks with 2 prn visits. -SN to perform/instruct caregiver procedure of wound care to the bilateral toes (both feet). -Goals: -Caregiver will demonstrate improved wound status by decreased size, drainage, no signs/symptoms of infection, decreased pain as a result of skilled intervention by 05/30/2021. Review of "Wound Assessment Tool Report" documentation revealed the following: 04/30/2021 (recertification visit): -Wound #1 (left great toe) measured 1.4 cm by 0.75 cm by 0.2 cm and that the RN (employee #13) documented wound monitoring would continue. -Wound #2 (left third toe) measured 0.2 cm by 0.2 cm by 0.2 cm and that the RN documented wound monitoring would continue. -Wound #3 (left fifth toe) measured 0.2 cm by 0.2 cm by 0.2 cm and that the RN documented wound monitoring would continue. -Wound #5 (left great toe) measured 0.5 cm by 0.5 cm by 0.2 cm and that the RN documented wound monitoring would continue. 05/19/2021: -Wound #1 (left great toe) measured 1.2 cm by 1.0 cm 0 and the LPN (employee #14) documented that wound was necrotic and that wound monitoring would continue. -Wound #2 (left third toe) measured 0.4 cm by 5 cm by 0 and that the LPN documented that wound monitoring would continue. -Wound #3 (left fifth toe) measured 0.3 cm by 0.2 cm by 0, the LPN documented that wound was necrotic and that monitoring would continue. There was no documentation in the clinical record which provided evidence that the supervising clinician/RN (employee #13) ensured that wound measurements of wounds #1, #2, #3 and #5 were obtained during the SN visits performed by the LPN (employee #14) on 05/05/2021 and 05/12/2021, nor during the final SN visit performed by the RN (employee #3) on 05/26/2021. There was no documentation in the clinical record which provided evidence that the supervising clinician/RN (employee #13) ensured that wound measurements of wound #5 were obtained during the SN visit performed by the LPN (employee #14) on 05/19/2021, nor during the final SN visit performed by the RN (employee #3) on 05/26/2021. During interview conducted on December 3, 2021 at approximately 2:20 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that the above referenced wounds were measured on the aforementioned dates for the above identified patients.