Every finding on record at Visiting Nurses Association Western Pennsylvania

Based on the findings of an onsite unannounced Medicare recertification survey completed April 21, 2021, Visiting Nurses Association of Western Pa 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 survey completed April 21, 2021, Visiting Nurses Association of Western Pa 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. The survey was conducted from the parent location.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, clinical records (CR), staff (EMP) interview, and observations during home visits (HV), the agency failed to include all medications on the plan of care for three (3) of three (3) home visits when medication lists were observed (HV3, HV4, & HV5). Findings included: Review of agency policy on April 19, 2021, at 2:15 p.m. showed, "Policy Title: Plan of Treatment/Care ... home health ... At the time of the initial and subsequent assessments, the assessing clinician will obtain, evaluate, and update general and medical information pertaining to the patient. The information includes, but is not limited to, ... current medications." Review of agency policy on April 19, 2021, at 2:15 p.m. showed, "Medication Policy ... On each visit, the clinician is expected to review and update the medication list in the home and in the computerized documentation. ... The clinician shall update the medication profile ... and the updated profile will be added to subsequent plans of care to be signed by the physician. ... Medication Reconciliation is completed ... At each visit, the clinician should assess the patient's medications for a. changes prescribed or self-prescribed b. additions of any over the counter medications c. self-made changes to the prescribed order, such as dose changes or frequency changes." Observation during HV3 on April 16, 2021 at 11:20 a.m. revealed the patient's most recent plan of care/medication list, printed on 4/15/2021, was not accurate and did not contain all of the medications the patient was taking. Interviews with the patient and his wife (caregiver) showed the following medications had been discontinued but still appeared as active on the patient's medication list: protonix, methocarbamol, Cymbalta, welchol, Plavix and bisacodyl. His wife stated, "he hasn't taken those for weeks if not months." It was also noted the patient was taking the following medications but they did not appear on the patient's medication list: Men's 50+ daily vitamin, duricef 500mg (milligrams) one tablet daily, ibuprofen 200mg (milligrams) 2 tablets every 6 hours as needed, gabapentin 100mg (milligrams) one tablet every night before sleep and Aleve over the counter as directed. The patient's wife confirmed the patient, "has been taking these all for months." Interview with EMP1 on 4/21/2021 at 10:25 a.m. confirmed findings and that the patient's plan of care/medication list was not accurate and did not contain all of the medications he was taking. Observation during HV4 on April 16, 2021, at 1:25 p.m. revealed a bottle of antibiotic medication "Clindamycin 150mg [milligrams] 4 by mouth one hour prior to invasive dental treatment." Interview with the patient at time of observation confirmed she was at the dentist's office today and was given clindamycin. She noted she needs to take due to a heart condition and also for her artificial knees. Review of patient's most recent medication list/plan of care (printed on 4/15/2021) during the home visit did not show it contained clindamycin. Interview with EMP2 on April 21, 2021, at approximately 9:30 a.m. confirmed findings. Observation during HV5 on April 16, 2021, at 2:10 p.m. revealed a bottle of Tylenol (medication) on a table behind where patient was seated in dining area. When patient was asked about the medication, "I just take it if I get to hurtin' throughout the day." When asked how long he had been taking/using he noted, "good while." Additional review of the medication bottle showed it was "Tylenol Extra Strength 500mg [milligrams] each 100 capsules." Review of patient's most recent medication list/plan of care (printed on 4/15/2021) during the home visit did not show it contained Tylenol extra strength. Interview with EMP10 at time of observation confirmed findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to promptly notify the physician to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered for three (3) of 17 records reviewed (CR3, CR6, & CR17). Findings included: Review of agency policy on April 21, 2021, at 9:17 a.m. showed, "Policy Statement: ... Orders are obtained, reviewed and revised according to each patient's needs in response to: changes in the patient's physical or psychosocial condition." Review of CR3 on April 15, 2021, at 1:20 p.m. showed a physician ordered plan of care beginning 10/27/2020 for an initial certification period ending 12/25/2020. Admitting diagnosis was type 1 diabetes with hyperglycemia (elevated blood sugar). Skilled nursing was to see the patient 1 time per week for assessment. Per orders on plan of care, "Instruct patient/caregiver on signs and symptoms of Hyperglycemia to include ... frequent urination." Per 11/5/2020 telehealth note by agency nurse, "Description of abnormal findings and other comments not already identified ... Pt. said that he has urinary frequency during the night and that he was up 6/7 times during the night to void, he said he will report this to his PCP [physician] at appointment tomorrow." Interview with EMP2 on April 21, 2021, at 10 a.m. confirmed agency telehealth nurse did not notify physician concerning patient's increased urinary frequency and that this was permissible since the patient was scheduled to see his physician the following day. On 11/24/2020, the physical therapist documented, "Spoke with patient this AM, reports went to the ER yesterday due to sugar shock but was discharged home, he has an appointment with his endocrinologist [diabetes doctor and not the attending]." Another interview with EMP2 on April 21, 2021, at 11:30 a.m. confirmed the physician was not notified of patient's ER visit due to elevated blood sugars. EMP2 asserted notification to patient's attending (certifying physician) was not necessary since the patient was to see his endocrinologist (not the attending) the next day. Review of CR6 on April 15, 2021, at 11:15 a.m. showed a physician ordered plan of care beginning 2/22/2021 for an initial certification period ending 4/23/2021. Admitting diagnosis was CHF (congestive heart failure [a disease were fluctuations in body weight can adversely affect outcomes]). Skilled nursing was ordered to see the patient 2 times per week for 1week then 1 time per week for 7 weeks for assessment as well as telemonitoring assessment daily. Per the plan of care, "Instruct patient/caregiver to notify their health care provider of weight gain of 3 lbs [pounds] in 1 day." The patient's clinical record from telehealth showed the following weight gains: 3/28/2021 155 pounds and 3/29/2021 161.4 pounds or a 6.4 pound gain 4/4/2021 159 pounds and 4/5/2021 162.2 pounds or a 3.2 pound gain 4/13/2021 156.2 pounds and 4/14/2021 161.8 pounds or 5.4 pound gain Interview with EMP2 on April 21, 2021, at 10:15 a.m. confirmed findings and no physician notification for increased weight. EMP2 asserted that he/she would not expect telehealth nurse to notify the physician since the patient was not symptomatic otherwise (short of breath). Review of CR17 on April 20, 2021, at 9:18 a.m. showed a physician ordered plan of care beginning 4/2/2021 for an initial certification period ending 5/31/2021. Admitting diagnosis was heart failure (CHF). Skilled nursing was ordered to see the patient 2 times per week for assessment. Per the plan of care, "Instruct patient/caregiver to notify their health care provider of weight gain of 3 lbs [pounds] in 1 day." The patient's clinical record from telehealth showed a reported weight of 340 pounds on 4/7/2021 and a reported weight of 343.5 pounds on 4/8/2021. Per telehealth note, "4/8/2021 09:30 [a.m.] Called Patient: wt [weight] up 3.5# overnight." Interview with EMP2 on April 21, 2021, at 10:22 a.m. confirmed findings and no physician notification for increased weight. EMP2 asserted that he/she would not expect telehealth nurse to notify the physician since patient was not symptomatic and that there were no specific orders for weight parameters at that time; however, orders were received on 4/9/2021 to notify physician for weight gain above 3 pounds. Per heart failure packet reviewed on April 20, 2021 at 1:36 p.m. and given to patient (CR17) at start of care, "Home Health Care Heart Failure Exacerbation ... refers to heart failure symptoms that get worse. Heart failure exacerbation is a serious medical problem that should be treated right away. ... How Is This Treated ... Monitoring your weight and reporting changes to your health care provider. ... Contact a Health Care Provider If: ... You gain 2/3 pounds ... in 24 hours."

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, directions for use, staff (EMP) interview, and observations during home visits, two (2) of seven (7) staff observed failed to follow agency policy and procedure for bag technique and cleaning and disinfection of equipment (EMP9 and EMP14). Findings included: Review of "Bag Technique" on April 21, 2021, at 9:20 a.m. showed, "The purpose of bag technique is to prevent cross-contamination between patients via the visit bag and supplies it contains. 1. Place bag on a clean, dry surface with a water-resistant barrier placed between the bag and the surface. ... 2. Perform hand hygiene ... before entering the bag. 4. Provide patient care. ... 5. Clean a all reusable items and place on bag flap to dry prior to returning to bag ... 6. Perform hand hygiene and return items to bag." Review of "Competency Validation Form Bag Procedure" on April 21, 2021, at 9:30 a.m. showed, "2. Once in the home, select a clean dry surface for the bag." Observation during a home visit on April 16, 2021, at 1:02 p.m. was conducted with the physical therapist (EMP9) and surveyor #2. EMP9 removed equipment from bag and placed blood pressure cuff on patient's arm. Once EMP9 obtained reading, he/she placed used cuff into right uniform pocket with clean supplies including a bottle of hand sanitizer and disinfectant wipes (previously clean items). Surveyor attempted to confirm findings with EMP9 after the observation but EMP9 noted, "If that's what you saw then that's what you saw." Interview with surveyor 2 at 1:26 p.m., who was also present during the observation, confirmed findings, and that EMP9 placed used patient care item into scrub top pocket with previously clean items. No mention in agency policy to show that placing used patient care items in uniform pockets with clean items is an acceptable practice. Observation during home visit on April 17, 2021, at 10:17 a.m. revealed nurse (EMP14) place paper barriers on carpeted floor and on upholstered chair (not clean surfaces as indicated in agency policy). EMP14 then placed laptop on chair and supply bag on floor (both on barriers). Once the visit was completed, EMP14 used disinfectant wipe on laptop and then immediately placed it into supply bag without letting it dry or performing hand hygiene. Interview with EMP14 at 10:41 a.m. confirmed findings and that she did not wait 2 minutes (noted below) nor perform hand hygiene prior to returning laptop to supply bag. Review of disinfectant used by EMP14 was conducted after the visit at 10:45 a.m. and showed, "TO DISINFECT ... Allow treated surface to remain wet for a full two (2) minutes."