Penn Highlands Community Nurses

The agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for three (3) of seven (7) observations providing direct care to patients (OBV1, OBV2 and OBV5).

The agency failed to maintain an accurate medication profile and to ensure review of potential adverse effects for one (1) of fourteen (17) medical records reviewed (MR17).

Complaint intake documentation during pre-survey preparation and staff (EMP) interviews the facility failed to ensure that all patient orders, including verbal orders were recorded in the plan of care and implemented for one (1) of one (1) discharged record reviewed. [G576], the agency failed to…

Agency failed to ensure skilled professional assumed responsibility, as per agency policy and procedure and job description, for the ongoing development, evaluation and implementation of the plan of care based on the orders of the physician for one (1) of five (5) discharged record and four (4) of…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity in order to provide optimal care and patient outcomes.

Staff (EMP) interviews the agency failed to provide services as per all written and verbal physician orders for one (1) of five (5) discharged record reviewed (CR1) and three (3) of twelve (12) active records reviewed (CR4, CR9, CR14) Findings Included: A review of agency policy and procedure was…

Staff (EMP) interviews the agency failed to ensure that the plan of care was reviewed and revised to reflect physician's orders based on significant changes to the patient's condition for (1) of one (1) discharged clinical record reviewed.

Complaint intake documentation and staff (EMP) interviews the agency failed to ensure staff were coordinating all identified patient changes and concerns with others involved in the patient's care to ensure uninterrupted care for one (1) of one (1) discharged record with significant condition…

Agency failed to ensure skilled professional assumed responsibility, as per agency policy and procedure and job description, for the ongoing development, evaluation and implementation of the plan of care based on the orders of the physician for one (1) of five (5) discharged record (CR1) and four…

Complaint intake documentation and staff (EMP) interviews the facility failed to ensure that all patient orders, including verbal orders were recorded in the plan of care and implemented for one (1) of one (1) discharged record reviewed (CR1).

Staff (EMP) interviews the agency failed to ensure that all verbal orders were documented and authenticated by the physician for one (1) of one (1) discharged records reviewed (CR1).

The agency failed to communicate to the patient and/or representative revisions to the plan of care due to a significant change in the patient's heath status for one (1) of one (1) discharged clinical records.

Complaint intake documentation and staff (EMP) interviews the agency failed to integrate all orders from the physician involved in the plan of care to assure timely coordination of services and interventions were provided to the patient for one (1) of five (5) discharged records reviewed (CR1) and…

The agency failed to involve the patient and/or patient representative in the coordination of care to meet their needs for one (1) of five (5) discharge records reviewed.

CR findings need tweaked to show the lack of development and evaluation of the POC Based on review of agency policy and procedures, agency job descriptions, clinical records, and staff interview, the agency failed to ensure the registered nurse made necessary revisions to the plan of care based on…

The skilled professional failed to provide services in accordance with the written orders of the physician for one (1) of one (1) discharged record (CR1) and three (3) of three (3) active CRs reviewed (CR4, CR9, CR14) with significant changes to the plan of care Findings Included: When reviewed…

Complaint intake documentation and staff (EMP) interviews the skilled professional failed to ensure coordination for patient care occurred for one (1) of one (1) discharged record with significant condition changes (CR1) and two (2) of two (2) active records reviewed with identified patient care…

The agency failed to ensure that referrals for additional services were coordinated and implemented timely for two (2) of two (2) active CRs reviewed with referrals for additional services.

Staff (EMP) interviews the agency failed to assure the individualized plan of care, including all updates, were fully implemented as per all written and verbal physician orders for one (1) of five (5) discharged record reviewed (CR1) and three (3) of twelve (12) active records reviewed (CR4, CR9…

The agency failed to ensure lines of authority for administrative control and delegation of responsibility were clearly set forth in writing and failed to ensure administrative/supervisory functions were not delegated to another agency or organization.

The agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for (2) of seven (7) observed providing direct care to patients (EMP8, EMP12).

The agency failed to disclose to the state survey agency of changes in management from 6/1/17 to 2/20/18. Findings Included: Pre-Survey Preparation conducted on 2/13/18 at approximately 8:00 a.m. revealed: A review of the agency facility profile revealed that the EMP5 was listed as the current…

The agency failed to ensure that responsibilities and obligations of the agency were clearly being carried out by an administrator appointed by the governing body from 6/1/17 to 2/20/18. Findings Included: Pre-Survey Preparation conducted on 2/13/18 at approximately 8:00 a.m. revealed: A review of…

The agency failed to promptly alert the physician to changes in the patient's condition or needs that suggested that the plan of care should be altered for two (2) of seventeen (17) CRs reviewed (CR3, CR6).

Agency failed to ensure wound care measurements were completed as per agency policy and procedure and the plan of care for six (6) of eight (8) CRs reviewed with documented wounds (CR1, CR2, CR5, CR6, CR8, CR10).

The agency failed to communicate to the physician changes in the patient's condition or needs that suggested that the plan of care should have been altered for two (2) of seventeen (17) CRs reviewed (CR3, CR6).

The agency failed to disclose to the state survey agency the name and address of each person who is a managing employee from 6/1/17 to 2/20/18. Findings Included: Pre-Survey Preparation conducted on 2/13/18 at approximately 8:00 a.m. revealed: A review of the agency facility profile revealed that…

The governing body failed to clearly appoint a qualified administrator between 6/1/17 to 2/20/18. Findings Included: Pre-Survey Preparation conducted on 2/13/18 at approximately 8:00 a.m. revealed: A review of the agency facility profile revealed that the EMP5 was listed as the current…

The governing body failed to clearly appoint a qualified administrator to oversee the day to day operations of the agency between 6/1/17 to 2/20/18. Findings Included: Pre-Survey Preparation conducted on 2/13/18 at approximately 8:00 a.m. revealed: A review of the agency facility profile revealed…

The governing body failed to clearly appoint a qualified backup administrator between 6/1/17 to 2/20/18. Findings Included: Pre-Survey Preparation conducted on 2/13/18 at approximately 8:00 a.m. revealed: A review of the agency facility profile revealed that the EMP5 was listed as the current…

The agency failed to ensure staff followed standards of practice and agency policy and procedure for (2) of seven (7) observed providing direct care to patients (EMP8, EMP12).

The agency failed to maintain accurate, complete clinical notes for two (2) of seventeen (17) CRs reviewed (CR1, CR16).