Every finding on record at VNA Home Health Services

Based on the findings of an unannounced onsite home health agency complaint investigation survey conducted 1/19/2022, Wellspan VNA, was found to be not in compliance with the following requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.

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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based upon review of agency policy, medical records (MR), interview with director of quality compliance (EMP # 1), agency failed to include type of service to be provided or frequency/duration of visits for one (1) of three (3) records reviewed. ( MR #1). Findings included: Review of agency policy on 1/19/2022 between approximately 2:30 PM-3:00 PM titled " Plan of Care Development and Review" stated " (5) The standard format for the POC {plan of care} includes, but is not limited to: Orders for services, treatment, and modalities, including frequency and duration of each, orders for frequency and duration of visits" " The Plan of Care, and the signed 485/487 are the basis for all care rendered." Review of MR on 1/19/2022 between approximately 11:15 AM-12:30 PM and 1:00 PM-2:00 PM revealed: MR # 1, Start of Care (SOC) 12/10/2021; eighty-one (81) year old male with diagnosis of infection and treatment of indwelling urethral catheter, pressure ulcers of sacrum and left heel end stage renal disease. Physician orders documented on referral 12/9/2021 for MSW{medical social worker}. No visit order or frequency or duration documented on 485 Plan of Care (12/10/2021-2/7/2022) for social work services. MSW documented phone call to patient's wife on 12/13/2021 and 12/16/2021 to assist with transportation resources. Initial MSW evaluation visit documented on 12/21/2021. No interim physian order produced for MSW services. Interview with EMP # 1 between approximately 3:00 PM-3:15 PM confirmed above findings.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based upon review of agency policy, medical records (MR), interview with director of quality compliance (EMP # 1), agency failed to obtain signed physician orders within 30 days for one (1) of three (3) records reviewed. ( MR #1). Findings included: Review of agency policy on 1/19/2022 between approximately 2:30 PM-3:00 PM titled " Plan of Care Tracking" stated " The medical records specialist (MRS) facilitates the tracking system for assuring that Plans of care (POC) are signed and returned within 30 days." This includes initial and recertification Plans of Care." Review of MR on 1/19/2022 between approximately 11:15 AM-12:30 PM and 1:00 PM-2:00 PM revealed: MR # 1, Start of Care (SOC) 12/10/2021; eighty-one (81) year old male with diagnosis of infection and treatment of indwelling urethral catheter, pressure ulcers of sacrum and left heel end stage renal disease. Physician orders (12/10/2021-2/7/2022) were signed and dated on 1/13/2022. (34 days later). Interview with EMP # 1 between approximately 3:00 PM-3:15 PM confirmed above findings.