Every finding on record at Signal PA Home Health, LLC

Based on the findings of an unannounced, onsite Medicare recertification survey conducted December 16 through December 18, 2024, Personal Home Healthcare and Hospice 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 December 16 through December 18, 2024, Personal Home Healthcare and Hospice 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.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on patient interview (Patients #6, #7 and #9) and interview with the administrator (Employee #9), the agency failed to ensure complete medication and treatment orders were included on initial “Home Health Certification and Plan of Care” for four (4) of eight (8) active patients. (Patients #6, #7, #9 and #13) Findings include: On December 18, 2024 at approximately 1:22 PM, review of the agency titled “Plan of Care-CMS #485 and Physician/Practitioner Orders” revealed the following under “Procedure”: 2. Each patient must receive an individualized written plan of care…The individualized plan of care must specify the care and services necessary to meet the patient specific needs… 4. The individualized plan of care must include the following…All medications and treatments… Patient #6: On December 17, 2024 at approximately 1:43 PM, review of the clinical record revealed a total of eight (8) medication orders are included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/13/2024 through 02/10/2025: During home visit conducted on 12/17/2024 at approximately 9:25 AM, review of home medication records revealed the patient is prescribed a total of 19 medications which includes, but is not limited to, Protonix (gastric reflux medication), Spiriva (inhaler) and Ubrelvy (migraine medication). During the interview conducted during the home visit, the patient confirmed the patient’s medication regime includes all 19 medications. There was no documentation which provided evidence that the “Home Health Certification and Plan of Care” includes all medications prescribed to the patient. Patient #7: On December 17, 2024 at approximately 1:57 PM, review of the clinical record revealed a total of 12 medication orders are included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/02/2024 through 01/30/2025: During home visit conducted on 12/17/2024 at approximately 10:15 AM, review of home medication records revealed the patient is prescribed a total of 14 medications which included Remeron (anti-depressant) and Xarelto (blood thinner-anticoagulant). During the interview conducted during the home visit, the patient confirmed the patient’s medication regime included all 14 medications. There was no documentation which provided evidence that the “Home Health Certification and Plan of Care” includes all medications prescribed to the patient. Patient #9: On December 17, 2024 at approximately 2:30 PM, review of the clinical record revealed a total of five (5) medication orders are included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/08/2024 through 02/05/2025: During home visit conducted on 12/18/2024 at approximately 8:25 AM, review of home medication records revealed the patient is prescribed a total of six (6) medications which included aspirin. During the interview conducted during the home visit, the patient confirmed the patient’s medication regime included all six (6) medications. There was no documentation which provided evidence that the “Home Health Certification and Plan of Care” includes all medications prescribed to the patient. Patient #13: On December 18, 2024 at approximately 11:30 AM, review of the clinical record revealed SN goals included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/06/2024 through 02/03/2025 include the following: Wound(s) will decrease in size by half by the end of episode. Review of wound treatment details included under “Orders/Treatments” on the initial “Home Health Certification and Plan of Care” included the following: Right anterior thigh: Calcium alginate daily; and Right anterior hip: Needs to be changed BID (twice a day). Review of the SN visit note dated 12/06/2024 revealed the RN (Employee #5) documented that the above referenced wounds were open and draining and that wound care was provided as per physician orders. There was no documentation in the clinical record which provided evidence that initial “Home Health Certification and Plan of Care” includes complete wound treatment orders for the above refenced wounds. During interview conducted on December 18, 2024 at approximately 1:45 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence the “Home Health Certification and Plan of Care” included complete medication and wound treatment orders for the above identified patients.

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 and clinical records, and based on interview with the administrator (Employee #9), the agency failed to ensure registered nursing (RN) staff performed skilled nursing (SN) assessments as per agency policy/procedure for three (3) of six (6) active patients for whom wound orders/treatments and/or goals were included on the “Home Health Certification and Plan of Care”. (Patients #5, #12 and #13) Findings include: On December 18, 2024 at approximately 1:25 PM, review of the agency titled “Skilled Professional Services” revealed the following under “Policy”: Patients receiving skilled professional services all receive appropriate assessments, reassessments…and care per physician/practitioner orders. Patient #5: On December 17, 2024 at approximately 1:20 PM, review of the clinical record revealed the “Home Health Certification and Plan of Care” for the initial certification period of 11/23/2024 through 01/21/2025 includes the following SN goals: Midline abdominal wound: Cleanse, pack with saline soaked gauze, ABD (thick dressing). Change daily. Review of the SN nursing visit note details revealed wound depth is included under in wound assessment category. Review of the SN visit note dated 12/04/2024 revealed the depth of the midline abdominal wound was 1.5 centimeters (cm). There was no documentation in the clinical record which provided evidence the registered nurse (RN-Employee #5) assessed the depth of the midline abdominal wound during the start of care visit on 11/23/2024. Patient #12: On December 18, 2024 at approximately 11:30 AM, review of the clinical record reveal the “Home Health Certification and Plan of Care” for the initial certification period of 11/20/2024 through 01/18/2025 includes the following SN orders/treatments: Patient to receive skilled nursing two (2) times a week for nine (9) weeks for wound assessment and wound care to left heel. Review of the SN nursing visit note details revealed wound depth is included under in wound assessment category. Review of the SN visit note dated 12/16/2024 revealed the depth of the left heel wound was 0.2 cm. There was no documentation in the clinical record which provided evidence the RN (Employee #10) assessed the depth of the left heel wound during the start of care visit on 11/20/2024. Patient #13: On December 18, 2024 at approximately 11:30 AM, review of the clinical record reveal the “Home Health Certification and Plan of Care” for the initial certification period of 12/06/2024 through 02/03/2025 includes the following SN goals: Wound(s) will decrease in size by half by the end of episode. Review of the SN nursing visit note details revealed wound depth is included under in wound assessment category. Review of the SN visit note dated 12/06/2024 revealed the RN (Employee #5) documented that the right anterior (front) thigh wound was open and that measurements of the wound included length and width. There was no documentation in the clinical record which provided evidence the RN (Employee #5) assessed the depth of the right anterior thigh wound during the start of care visit on 12/06/2024. During interview conducted on December 18, 2024 at approximately 1:55 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence the above identified RN’s assessed the wound depth for the above referenced wounds/patients.

Based on the findings of an unannounced, onsite Medicare incident investigation survey conducted on June 14, 2023, Personal Home Healthcare and Hospice 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.

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 review of agency policies and procedures and clinical records and based on interview with the administrator (Employee #1), the agency failed to ensure wound care was performed per physician orders for one (1) of two (2) patients for whom wound care was provided by agency staff. (Patient #1) Findings include: On June 14, 2023 at approximately 2:36 PM, review of the agency policy titled "Plan of Care-CMS #485 and Physician Orders" revealed the following: -Policy...Skilled nursing and other hoe health services will be in accordance with a plan of care... -Procedure...3. Each patient must receive the home health services that are written in an individualized plan of care... Patient #1: On June 14, 2023 at approximately 11:01 AM, review of the clinical record revealed the start of care date was 04/21/2023 and that skilled nursing (SN) is to provide the following wound care to the bilateral (both) lower extremity (legs) wounds as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 04/21/2023 through 06/19/2023: -Cleanse with normal saline solution (NSS), pat dry, apply Xeroform (medicated petroleum wound dressing), followed by dry sterile dressing. Change daily. Review of the initial "SN Evaluation" assessment note dated 04/22/2023 revealed wound #2 is located on the posterior (back) right lower leg and wound #3 is located on the posterior left lower leg. Review of SN visit note documentation revealed the LPN;s (Employee #2, #4 or #5) applied betadine to the wound bed of wounds #2 and #3 during the SN visits performed on 05/01, 05/05, 05/08, 05/10, 05/12, 05/15 and 05/18/2023. There was no documentation in the clinical record which provided evidence that the physician had provided an order to apply betadine to the wound bed of wounds #2 and #3. During interview on June 14, 2023 at approximately 2:43 PM, the administrator confirmed wound care was not provided as per physician orders by the above identified LPN's on the above referenced dates.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the administrator (Employee #1), the agency failed to ensure licensed practical nursing (LPN) staff coordinated patient care with a registered nurse (RN) for one (1) of three (3) patients. (Patient #1) Findings include: On June 14, 2023 at approximately 2:37 PM, review of the agency policy titled "Care Planning Process" revealed the following under "Procedure": 5. Care will be coordinated initially and ongoing among staff providing care... On June 14, 2023 at approximately 2:40 PM, review of the agency policy titled "Assessment and Reassessment Guidelines" revealed the following under "Procedure": 4. Communication: Pertinent assessment and reassessment fata will be communicated to team members...by case conference, telephone or in writing. Patient #1: On June 14, 2023 at approximately 11:01 AM, review of the clinical record revealed the start of care date was 04/21/2023 and that skilled nursing (SN) is to provide wound care to the wounds located on the bilateral (both) lower extremities (legs), the left buttock and the bilateral second toes as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 04/21/2023 through 06/19/2023. Review of the initial "SN Evaluation" assessment note dated 04/22/2023 revealed SN provided wound care to the left buttock wound, the left and right posterior (back) lower leg wounds and the left and right second toe wounds and that wound assessment included the following: -Wound #2 Right lower extremity (RLE) posterior: 0.5 centimeters (cm) by 0.5 cm by 0.1 cm (length by width by depth-L X W X D) with scant (minimal amount) of serosanguineous drainage (wound drainage which includes blood and yellow fluid), wound bed pink; and -Wound #3: Left lower extremity (LLE) posterior: 2.0 cm X 1.0 cm X 0.1 cm with scant amount of serosanguineous drainage, wound bed pink. Review of the SN visit note dated 05/01/2023 revealed wound assessment documented by the LPN (Employee #2) included the following: -Wound #2 RLE Posterior: 1.5 cm X 1.5 cm X 0.1 cm with large amount of serous drainage (thin/watery wound drainage), wound bed red; and - Wound #3 LLE Posterior: 2.0 cm X 2.0 cm by 0.1 cm with a large amount of serous drainage, wound bed red. Review of the SN visit note dated 05/05/2023 revealed a licensed practical nurse (Employee #5) notified the patient's physician and the Area Agency on Aging (AAA) of a lack of care at home and the possibility of the patient not being able to care for self (self-neglect). Review of the SN visit note dated 05/10/2023 revealed an LPN (Employee #2) notified the physician that a rash was present in the scrotal region. There was no documentation in the clinical record which provided evidence that the LPN's (Employee #2 and #5) had notified a RN of the following: -An increase in wound size/drainage volume and wound bed appearance change for wounds #2 and #3 as documented on 05/01/2023; -Concerns regarding possible self-neglect which were reported to the patient's physician and AAA on 05/05/2023; nor -The scrotal region rash which was reported to the physician on 05/10/2023. During interview on June 14, 2023 at approximately 2:43 PM, the administrator confirmed the LPN's (Employees #2 and #5) failed to notify a RN of the above referenced assessment findings and self-care concerns (self-neglect) for patient #1.

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 and clinical records and the Pennsylvania (PA) Department of Health (DOH) Event Reporting System (ERS) website, and based on interview with the administrator (Employee #1), the agency failed to submit one (1) of two (2) reports of patient self-neglect, which occurred in 2023, to the PA DOH ERS website prior to June 14, 2023. (Patient #1) Findings include: On June 14, 2023 at approximately 2:43 PM, review of the agency policy titled "Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation" revealed the following under "Procedure": 2. Any agency staff...who identified, notices or recognizes incidences or circumstances of...neglect...must report the findings immediately (within 24 hours) to the agency and other appropriate authorities in accordance with state law. Patient #1: On June 14, 2023 at approximately 11:01 AM, review of the clinical record revealed the start of care date was 04/21/2023 and that skilled nursing (SN) is to provide wound care to the wounds located on the bilateral (both) lower extremities (legs), the left buttock and the bilateral second toes as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 04/21/2023 through 06/19/2023. Review of the initial "SN Evaluation" assessment note dated 04/22/2023 revealed the patient is 92 years old, the patient resides alone, that a neighbor stops in daily to assist when needed and that SN provided wound care to the left buttock wound, the left and right posterior (back) lower leg wounds and the left and right second toe wounds. Review of the SN visit note dated 05/05/2023 revealed a licensed practical nurse (Employee #5) notified the patient's physician and the Area Agency on Aging of a lack of care at home and the possibility of the patient not being able to care for self. On June 14, 2023 at approximately 1:05 PM, review of PA DOH ERS website documentation failed to reveal that the agency had submitted a report related to self-neglect of patient #1 prior to 06/14/2023. During interview on June 14, 2023 at approximately 2:43 PM, the administrator confirmed the agency failed to submit a report for the above referenced concerns related to self-neglect to the PA DOH ERS website prior to 06/14/2023.

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 and procedures and clinical records and based on interview with the administrator (Employee #1), the agency failed to ensure patient assessment was completed by licensed practical nursing (LPN) staff per agency policy and procedure for two (2) of three (3) patients. (Patients #1 and #2) Findings include: On June 14, 2023 at approximately 2:38 PM, review of the agency policy titled "Skilled Professional Services" revealed the following under "Policy": Patients receiving skilled professional services will receive appropriate assessments, reassessments... On June 14, 2023 at approximately 2:42 PM, review of the agency policy titled "Reassessment/Update of the Comprehensive Assessment" revealed the following under "Procedure": 3. Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs... Patient #1: On June 14, 2023 at approximately 11:01 AM, review of the clinical record revealed the start of care date was 04/21/2023 and that skilled nursing (SN) is to assess for skin breakdown every visit as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 04/21/2023 through 06/19/2023. Review of the SN visit note dated 05/10/2023 revealed an LPN (Employee #2) notified the physician that a rash was present in the scrotal region. There was no documentation in the clinical record which provided evidence the LPN (Employee #2) assessed the scrotal area rash during the SN visit conducted on 05/12/2023. Patient #2: On June 14, 2023 at approximately 1:07 PM, review of the clinical record revealed the start of care date was 03/11/2023, that wound care was ordered for the left heel wound and that SN goals included for the wounds to size to decrease as documented on the "Home Health Certification and Plan of Care" for the recertification period of 05/11/2023 through 07/09/2023. Review of the SN recertification assessment dated 05/10/2023 revealed the left heel wound measured 0.3 centimeters (cm) by 0.3 cm by 0.1 cm (length by width by depth-L X W X D) Review of the SN visit note dated 05/17/2023 revealed the left heel wound size increased to 1.2 cm X 1.0 cm by 0.5 cm. Review SN visit note documentation revealed a single SN visit was performed during the week of 05/28/23 through 06/03/2023 and that during the 05/30/2023 SN visit, the LPN (Employee #2) provided wound care to the left heel wound. There was no documentation in the clinical record which provided evidence the LPN (Employee #2) assessed the left heel wound size during the 05/30/2023 SN visit. During interview on June 14, 2023 at approximately 2:43 PM, the administrator confirmed the LPN (Employees #2) failed to perform patient assessment in accordance with agency policies and procedures for the above referenced patients.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on November 1 and November 2, 2021, Personal Home Healthcare and Hospice 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 November 1 and November 2, 2021, Personal Home Healthcare and Hospice was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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, personnel files and the Pennsylvania (PA) Department of Health (DOH) Event Reporting System (ERS) website, and based on interview with the administrator, the agency failed to submit a report of two (2) of two (2) COVID-19 related events to the PA DOH ERS website. Findings include: On November 1, 2021 at approximately 12:14 PM, review of the agency policy titled "Health Guidelines for Employees with Infectious Diseases" revealed the COVID-19 was an infectious disease. On November 1, 2021 at approximately 12:16 PM, review of the agency policy titled "Health Guidelines for Employees with Infectious Diseases" revealed the following: Procedure...3. Reportable communicable diseases are defined by local health departments. On November 1, 2021 at approximately 11:54 AM, review of the agency binder titled "PA DOH" revealed the PA DOH manual titled "Event Notification Internet Site Overview-Facilities Effective March 9, 2021" was maintained by the agency and that reporting instructions for COVID-19 positive cases for residents (patients) and staff were included on page 10 of the manual. On November 2, 2021 at approximately 3:08 PM, review of personnel files revealed the following: Employee #3: The date of hire of the registered nurse (RN) was 02/06/2021. Employee #6: The date of hire of the occupational therapist (OT) was 07/14/2021. On November 1, 2021 at approximately 11:30 AM, review of "Infection Control Log: Employee Infection" documentation revealed that a COVID-19 infection was recorded for employee #3 on 10/20/2021 and for employee #6 on 09/30/2021. On November 1, 2021 at approximately 8:14 AM, review of the PA DOH ERS website revealed there was no documentation on the PA DOH ERS website which provided evidence that the agency had submitted reports to the PA DOH ERS website under "Health Department Reportable Diseases"/subcategory COVID-19 for the above referenced COVID-19 related events. During interview on November 1, 2021 at approximately 3:40 PM, the administrator confirmed the agency failed to submit reports to the PA DOH ERS website for the above referenced COVID-19 related reportable events.