Every finding on record at Superior Health Services Inc

Based on the findings of an unannounced, onsite Medicare recertification survey conducted January 25 through January 27, 2021, Superior Health Services, Inc. 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 January 25 through January 27, 2021, Superior Health Services, Inc. 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.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the clinical manager and the administrator, the agency failed to ensure written notice of the agency's transfer and discharge policies were provided to five (5) of five (5) patients for whom a home visit was conducted. (Patients #5, #6, #7, #8 and #9) Finding include: On January 27, 2021 at approximately 2:08 PM, review of agency 1-001 policy, titled "Rights/Responsibilities" revealed the following: Purpose...To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning... Procedure...1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing are to the patient, of the following...U. The organization's transfer and discharge policies... On January 27, 2021 at approximately 2:06 PM, review of agency policy 2-040, titled "Transfer/Referral Criteria and Process" revealed that the purpose of the policy is to outline the process for transferring or referring a patient to another service provider. On January 27, 2021 at approximately 2:07 PM, review of agency policy 2-042, titled "Discharge Criteria and Process" revealed that the purpose of the policy is to outline the process for discharging a patient from home health services. On January 25, 2021 at approximately 10:49 AM, review of the agency admission folder failed to reveal that the patient rights notification forms had included the transfer policies/procedures included in policy 2-040 and the discharge policies/procedures included in policy 2-042. Patient #5: On January 26, 2021 at approximately 9:24 AM, review of the clinical record revealed the start of care date was 12/10/2020, the primary diagnosis is venous insufficiency (poor circulation), and that skilled nursing (SN) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 12/10/2020 through 02/07/2021. During a home visit conducted on January 26, 2021 at approximately 12:35 PM, review of the agency's admission folder revealed there was no documentation which provided evidence that the patient received written notification of the transfer policies/procedures included in policy 2-040 nor the discharge policies/procedures included in policy 2-042. Patient #6: On January 26, 2021 at approximately 10:04 AM, review of the clinical record revealed the start of care date was 12/02/2020, the primary diagnosis is Parkinson's disease, and that physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 12/02/2020 through 01/30/2021. During a home visit conducted on January 26, 2021 at approximately 2:00 PM, review of the agency's admission folder revealed there was no documentation which provided evidence that the patient received written notification of the transfer policies/procedures included in policy 2-040 nor the discharge policies/procedures included in policy 2-042. Patient #7: On January 26, 2021 at approximately 10:19 AM, review of the clinical record revealed the start of care date was 07/02/2020, the primary diagnosis is vitamin B12 deficiency, and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 12/29/2020 through 02/26/2021. During a home visit conducted on January 27, 2021 at approximately 9:00 AM, review of the agency's admission folder revealed there was no documentation which provided evidence that the patient received written notification of the transfer policies/procedures included in policy 2-040 nor the discharge policies/procedures included in policy 2-042. Patient #8: On January 26, 2021 at approximately 10:40 AM, review of the clinical record revealed the start of care date was 12/28/2020, the saddle embolus (blood clot) of the pulmonary (lung) artery, and that SN, PT and occupational therapy services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 12/28/2020 through 02/25/2021. During a home visit conducted on January 26, 2021 at approximately 1:05 PM, review of the agency's admission folder revealed there was no documentation which provided evidence that the patient received written notification of the transfer policies/procedures included in policy 2-040 nor the discharge policies/procedures included in policy 2-042. Patient #9: On January 27, 2021 at approximately 7:01 AM, review of the clinical record revealed the start of care date was 01/12/2021, the primary diagnosis is Type-2 diabetes mellitus (diabetes) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/12/2021 through 03/12/2021. During a home visit conducted on January 27, 2021 at approximately 10:10 AM, review of the agency's admission folder revealed there was no documentation which provided evidence that the patient received written notification of the transfer policies/procedures included in policy 2-040 nor the discharge policies/procedures included in policy 2-042. During interview on January 27, 2021 at approximately 2:30 PM, the clinical director and the administrator confirmed there was no documentation which provided evidence that the above identified patients had received written notification of the transfer policies/procedures included in policy 2-040 nor the discharge policies/procedures included in policy 2-042.

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 clinical records, and the Pennsylvania (PA) Department of Health (DOH) website documentation, and based on interview with the clinical manager and the administrator, the agency failed to submit three (3) of three (3) COVID-19 related events to the PA DOH Event Reporting System (ERS) website. Findings included: On January 27, 2021 at approximately 2:05 PM, review of agency policy 4-107 titled "Incident Reporting" revealed the following: Purpose: To define the reporting, follow-up, and feedback process for incidents involving patients and organization personnel... Procedure...6. Incidents requiring reporting to state and/or federal regulatory agencies...C. As applicable, the QAPI (Quality Assessment/Performance Improvement) Coordinator or designee will complete and submit necessary forms within the required time frame to the appropriate organization. On January 25, 2021 at approximately 8:30 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed that COVID-19 is a Health Department reportable disease. On January 27, 2021 at approximately 11:11 AM, review of the "Emergency Preparedness Exercise" dated March 3, 2020 revealed the agency EPP (Emergency Preparedness Plan) was activated by the agency as a result of a COVID-19 referral. On January 25, 2021 at approximately 3:48 PM, review of 2020 4th quarter "Acquired Infection" documentation revealed two (2) patients had tested positive for COVID-19. Patient #10: On January 27, 2021 at approximately 7:35 AM, review of the clinical record revealed the start of care date was 11/21/2020, the primary diagnosis was encounter for aftercare following surgery of the circulatory system and that COVID-19 was not a pre-admission diagnosis included on the "Home Health Certification and Plan of Care" for the initial certification period of 11/21/2020 through 01/19/2021. Review of skilled nurse visit note documentation dated 12/11/2020 revealed the patient tested positive for COVID-19 the prior day (12/10/2020). Patient #11: On January 27, 2021 at approximately 7:55 AM, review of the clinical record revealed the start of care date was 11/03/2020, the primary diagnosis was pleural effusion (fluid build-up in lung cavity) and that COVID-19 was not a pre-admission diagnosis included on the "Home Health Certification and Plan of Care" for the initial certification period of 11/03/2020 through 01/01/2021. Review of skilled nurse visit note documentation dated 11/04/2020 revealed the patient was transferred/admitted to the hospital due to a deterioration in respiratory status. During interview on January 26, 2021 at approximately 2:42 PM, the clinical manager confirmed that the patient was diagnosed with COVID-19 after the home health start of care date. On January 25, 2021 at approximately 8:20 AM, review of the PA DOH ERS website failed to reveal that the agency has submitted a report of activation of the COVID-19 EPP and the two (2) incidents of COVID-19 "Health Department Reportable Diseases" had been submitted to the PA DOH ERS website. During interview on January 27, 2021 at approximately 2:30 PM, the clinical manager and the administrator confirmed the agency failed to submit the above referenced reports to the PA DOH ERS website.