Heritage Health Care

Personnel files and based the agency failed to ensure initial TB screening was conducted in accordance with CDC and PA DOH recommendations for four (4) of four (4) active employees whose date of hire was after January 21, 2022. Personnel Files (PF) #1, #2, #3, and #4. Interview with agency staff…

The agency failed to follow the plan of care as directed by the physician for four (4) of eight (8) CRs reviewed.

The agency failed communicate with all physicians or allowed practitioners issuing orders for the plan of care regarding discharge and provide discharge summary for two (2) of eight (8) records reviewed.

The agency failed to provide supervision to physical therapy assistant providing services for four (4) of eight (8) CRs reviewed.

The agency failed to follow the physician's ordered plan of care for one (1) of seven (7) clinical records reviewed (CR4).

The agency failed to obtain a Clinical Laboratory Improvement Amendments (CLIA) waiver to perform in-home PT/INR (prothrombin time)/(international normalized ratio).

The agency failed to provide proof of the Governing Body's involvement in the appointment of the agency Administrator prior to the hire/appointment date of 12/01/2021. Findings included: A review of Agency "Employee Roster" on 10/27/2022 from approximately 12:30 p.m. to 1:00 p.m. revealed Agency…

PAC (professional advisory committee) documents and staff (EMP) interview the agency failed to implement, evaluate and maintain an effective, ongoing, Home Health Agency-wide, data-driven program and retain documentation of the program during 2017 and 2018. This condition was not met based on the…

The agency failed to develop and maintain an EPP that was reviewed and updated annually.

The agency failed to develop, maintain and review an emergency preparedness plan that included a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation…

The agency failed to participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based.

The agency failed to conform orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient and ensure that the client received all services as ordered by the physician for one (1) out of seven (7) records reviewed (MR#5).

The agency failed to coordinate care of the patient for two (2) of seven (7) records reviewed (MR#5 and MR7).

The agency failed to develop a QAPI program with performance improvement projects (PIP) that tracked patient adverse events, analyzed their causes and implemented preventative actions.

The agency failed to conduct performance improvement projects (PIP) that reflected the scope, complexity, and past performance of the agency's services and operations.

Staff (EMP) interview the agency Governing Body failed to ensure that an ongoing program for QAPI is defined, implemented and maintained, with efforts to address priorities for improved quality of care and patient safety.

Agency failed to maintain a governing body that assumes full legal authority and responsibility for the operation of the agency.

The therapy services failed to complete the comprehensive assessment no later than 5 calendar days after start of care for three (3) of five (5) MR reviewed (MR1, MR5 and MR6).

The agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking in order to identify and address potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicative therapy, and…

The agency failed to ensure all orders by the physician were submitted to the plan of care for one (1) out of seven (7) records reviewed.

The therapy services failed to complete the comprehensive assessment no later than 5 calendar days after start of care for three (3) of five (5) MR reviewed (MR1, MR5 and MR6) and the agency failed to ensure that the client received all services as ordered by the physician for one (1) out of seven…

The agency failed to provide evidence of a QAPI program with performance improvement projects (PIP) that takes actions aimed at performance improvement and measure its success and track performance to ensure that improvements are sustained.