Every finding on record at 24-7 Home Health Services, Inc.

The following reflects the findings of the Department of Public Health during a recertification survey. Representing the Department of Public Health: Surveyor: 43929 Surveyor: 44911 Sample Size: 7. Home visits: 3

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7) were advised regarding information for Federal and State funded entities where the patients reside. This failure had the potential to result in patients not having knowledge of the services available to them. A review of Patient 1 (P1)’s “Patient Information” sheet indicated a Start of Care Date of 11/28/22, with diagnosis that included diabetes mellitus (a disease in which blood sugar levels are too high). A review of Patient 2 (P2)’s “Patient Information” sheet indicated a Start of Care date of 9/13/22, with a diagnosis of spinal stenosis (this happens when the spaces in the spine narrow and create pressure on the spinal cord). A review of Patient 3 (P3)’s “Patient Information” sheet indicated a Start of Care date of 9/29/22, with diagnosis of critical illness polyneuropathy (a disease affecting the nerves of the arms and legs). A review of Patient 4 (P4)’s “Patient Information” sheet indicated a Start of Care date of 12/4/22, with a diagnosis of chronic peripheral venous insufficiency (condition when the veins have trouble sending blood from the limbs back to the heart that has developed over time). A review of Patient 5 (P5)’s “Patient Information” sheet indicated a Start of Care date of 9/23/22, with diagnosis of metabolic encephalopathy (a series of brain dysfunctions). A review of Patient 6 (P6)’s “Patient Information” sheet indicated a s Start of Care date of, 9/15/22 with a diagnosis of Type 2 diabetes mellitus (a disease in which blood sugar levels are too high). A review of Patient 7 (P7)’s “Patient Information” sheet indicated a Start of Care date of 11/28/22, with a diagnosis of a fracture of the left femur (thigh). During an interview on 1/12/23, at 1:20 p.m., the administrator (ADM) stated, the admission folder did not have information for the state and federal funded entities. The ADM stated, the social worker was responsible for providing this information. A review of the HHA’s undated record titled, “Patient Handbook & Orientation for Home Health Care”, did not have information on Federal and State funded entities where the patients reside.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, interviews, and record review, the home health agency (HHA) failed to review the medications for accuracy for one of seven (Patient 1) sampled patients. This deficient practice had the potential to result in the patient not receiving the proper medication therapy or experience adverse reactions. A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/28/2022, with a primary diagnosis of diabetes mellitus (DM, a disease in which blood sugar levels are too high) and secondary diagnoses of diabetes mellitus with diabetic polyneuropathy (group of disorders caused by damage to peripheral nerves), hyponatremia (a lower than normal level of sodium in the bloodstream), hypokalemia (a lower than normal potassium level in the bloodstream), hypertensive heart disease (HTN heart disease, heart problems that occur because of high blood pressure that is present over a long period of time) without heart failure (when the heart muscle does not pump blood as well as it should), hyperlipidemia (HLD, a condition in which there are high levels of fat particles in the blood), radiculopathy in lumbar region (inflammation of a nerve root in the lower back which causes pain or irritation in the back and down the legs), and schizoaffective disorder (a mental health condition including schizophrenia which is a mental disorder that affects a person’s ability to think, feel, and behave clearly and mood disorder symptoms that can include depression or bipolar disorder), seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), history of transient ischemic attack (TIA, also called “mini stroke”, is caused by a temporary disruption in the blood supply to part of the brain which results in a lack of oxygen to the brain), generalized anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities), and presence of cardiac pacemaker (an electronic device that is implanted in the body to monitor heart rate and rhythm, giving the heart electrical stimulation when it does not beat normally). A review of Patient 1’s Plan of Care (POC) for certification period 11/28/2022 to 1/26/2023 and Medication Profile, the POC indicated the Skilled Nurse (SN) was to visit Patient 1 twice a week for nine weeks for the assessment and observation of vital signs (VS, clinical measurements that indicate the state of a patient’s essential body functions including pulse rate, temperature, respiration rate, and blood pressure), response to medication/treatment and proper management at home. Patient 1’s POC and Medication Profile indicated the current medications as follows: - Clonazepam 1mg tablet, one tablet by mouth once daily at bedtime for seizures - Ergocalciferol 50,000 units capsule, one capsule by mouth once weekly for supplements - Gabapentin 100mg tablet, one tablet by mouth three times a day for nerve pain - Risperidone 3mg tablet, one tablet by mouth once daily at bedtime for schizophrenia - Zolpidem Tartrate 5mg tablet, one tablet by mouth once daily for insomnia On 1/11/2023 at 2:58 PM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 1’s regional center living facility. Patient 1 was resting in the facility’s living area watching television. LVN 1 asked Patient 1 to go to Patient 1’s room to conduct SN visit. Patient 1 agreed. During a concurrent interview and record review of Patient 1’s medications on 1/11/2023 at 3:26 PM with LVN 1 and regional center administrator (RCADM) of Patient 1’s Medication Profile, inaccuracies were noted for the following medications: - Clonazepam, RCADM stated medication is being held since 12/2022, LVN 1 stated she was not aware of the medication being held. - Ergocalciferol 50,000 units capsule, RCADM stated this medication was not being administered but was changed to Vitamin D3 50 micrograms (mcg, unit of weight) tablet, Patient 1 is to take one tablet by mouth daily per the facility order for Patient 1. LVN 1 stated she was not aware of the change in the medication. - Gabapentin 100mg tablet, RCADM stated the medication concentration being administered to Patient 1 is 300mg, not 100mg. LVN 1 stated she was aware of the change in concentration approximately two to three SN visits prior. LVN 1 stated she does not know why the Medication Profile for Patient 1 had not been changed. - Risperidone 3mg tablet, RCADM stated medication had been held and not administered to Patient 1 since 12/2022. LVN 1 stated she was not aware of the medication being held. - Zolpidem Tartrate 5mg tablet, RCADM stated this medication has been discontinued and Patient 1 is no longer taking this medication. LVN 1 agreed the medication is still listed on Patient 1’s current Medication Profile. LVN 1 stated she was not aware this medication had been discontinued. During an interview on 1/11/2023 at 3:38 PM with LVN 1, LVN 1 stated she is required to check the medications during every SN visit. LVN 1 stated she may have made a mistake in properly saving the changes about the concentration for Gabapentin. LVN 1 stated she is required to communicate with the HHA’s Director of Patient Care Services (DPCS) regarding any changes of the medications. LVN 1 stated the importance of reviewing Patient 1’s medications was to ensure the patient is taking the correct medication therapy, to assess for any side effects, to make sure the Medication Profile is correct and updated regarding the patient’s current medications. During an interview on 1/12/2023 at 10:03 AM with DPCS, DPCS stated the SN is required to review the medications for any changes, discontinued medications, and any changes in dosages, regardless of what the RCADM verbally states about the medications during the SN visit. DPCS stated it is important for the SN to review the medications during every SN visit is to assess and identify any side effects, interactions, and to ensure the proper therapy for Patient 1. A review of the HHA’s undated policy and procedure (P&P) titled, “Medication Profile”, the P&P indicated a patient will have a current, accurate medication profile in the clinical record and the medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. The P&P indicated during home visits, the medication profile will be used as a care planning and teaching guide to ensure the patient and family/caregiver as well as other clinicians understand the medication regimen which includes using the medication profile to evaluate the use of medications in the home setting. The P&P indicated the medication profile includes all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and drug and/or food allergies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure patients received services according to the Plan of Care (POC) for two of seven sampled patients (Patient 3 and Patient 5). This deficient practice had the potential to result in a delay in treatment goals by not receiving the visits as indicated in the POC. a. A review of Patient 3 (P3)’s “Patient Information” sheet indicated a Start of Care date of 9/29/22, with a diagnosis of critical illness polyneuropathy (a disease affecting the nerves of the arms and legs). During an interview on 1/12/23, at 10:45 a.m., the Administrator (ADM) stated the process for missed visits is to reschedule for the same week, so the patient does not miss the service. The ADM stated if missed visits continue for the following week, the doctor is notified of the missed visits. A review of P3’s record titled, “Home Health Certification and Plan of Care”, for the certification period 11/28/22-1/26/23, indicated, “21. Physical Therapy: For evaluation and treatment.” A review of P3’s record titled, “Physician Order”, dated 12/9/22, indicated, “Orders PT (physical therapy) skilled services 1w1 (one a week for one week), 2w3 (2 times a week for 3 weeks). Further review of P3’s medical record indicated missed PT visits on 12/13/22, 12/15/22, and 12/20/22. The HHA did not document the rescheduling attempts, reason for missed visits, and notification to the doctor of the missed visits. b. A review of Patient 5 (P5)’s “Patient Information” sheet indicated a Start of Care date of 9/23/22, with a diagnosis of metabolic encephalopathy (a series of brain dysfunctions). During an interview on 1/12/23, at 10:50 a.m., the ADM stated Patient 5 (P5) was to have occupational therapy at the beginning of the certification period starting 11/22/22. The ADM stated there was no reason documented as to why the OT visits were not done. The ADM stated the agency “did not do our due diligence to document in the patient’s records.” A review of P5’s record titled, “Home Health Certification and Plan of Care”, for certification period 11/22/22-1/20/23, indicated, “…21.Orders for discipline and treatments…Occupational Therapy: Continue OT visits…”. Further review of P5’s medical record indicated the OT began to continue OT therapy on 12/1/22. The HHA did not document the rescheduling attempts, reason for missed visits, and notification to the doctor of the missed visits. A review of the HHA’s undated policy and procedure titled, “Care Planning Process”, indicated, “…Procedure…5. The plan of care will be based upon the physician’s…orders and will encompass the…services required to meet the patient’s needs.” A review of the HHA’s undated policy and procedure titled, “Missed Visits”, indicated, if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will document in the patient’s clinical record the following information: Reason for the missed visit and physician notification.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to document the Certified Home Health Aide (CHHA) supervisory visits for one of seven (Patient 2) sampled patients. This deficient practice had the potential to result in the improper CHHA care of the patient. A review of Patient 2’s profile indicated a Start of Care (SOC) date of 9/13/2022 with a primary diagnosis of spinal stenosis (condition when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots) of the thoracic (middle section of the spine) and lumbosacral (the area of the spine that makes up the lower back) regions with secondary diagnoses of diabetes mellitus (a disease in which blood sugar levels are too high), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long period of time) without heart failure (when the heart muscle does not pump blood as well as it should). A review of Patient 2’s Plan of Care (POC) for the certification period 11/12/2022 to 1/10/2023 indicated CHHA is to visit three times a week for eight weeks. The POC indicated CHHA to provide assistance with activities of daily living (ADLs, activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). During the entrance conference on 1/10/2023 at 12:02 PM with the HHA’s Director of Patient Care Services (DPCS), the DPCS stated the HHA uses an electronic documentation system and all visit notes from the Skilled Nurses (SN) and CHHAs should be input within 72 hours of visit or the following Monday. An electronic medical record review on 1/10/2023 of Patient 2’s CHHA supervisory visit notes dated 12/9/2023 and 12/23/2022 indicated the notes were “in progress” instead of “submitted”. During a concurrent interview and electronic record review on 1/12/2023 at 10:03 AM with DPCS of Patient 2’s electronic medical chart, DPCS stated CHHA supervisory visits should be conducted every 14 days to monitor the duties provided by the CHHA and the Registered Nurse (RN) should input the supervisory visit notes in the computer within 72 hours of the visit or the following Monday. DPCS verified the CHHA supervisory visits dated 12/9/2022 and 12/23/2022 indicated they have not been completed and were “in progress” where it should indicate they were “submitted”. DPCS verified the CHHA supervisory visit notes reviewed on 1/10/2023 were blank and were “in progress” instead of “submitted”. DPCS was unable to provide reasons for the delay in the input of the CHHA supervisory visit notes into the electronic computer system. DPCS stated the importance of documenting the CHHA supervisory visits into the computer charting system was to track what visit was completed and what was assessed during the supervisory visit. A review of the HHA’s undated policy and procedure (P&P) titled, “Home Health Aide Supervisory Visits”, the P&P indicated the supervisory visits must be conducted no less frequently than every 14 days. The P&P indicated the RN and/or appropriate skilled professional will be responsible for documentation of all pertinent clinical notes, which may include observations made by the aide. The P&P indicated supervisory visits and overall supervision will be documented in the clinical record. The P&P indicated the supervisory visits will be documented on a supervisory visit form and each supervisory visit shall contain documentation to ensure that the aide is furnishing care in a safe and effective manner.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to accurately re-assess the pain level for one of seven (Patient 2) sampled patients. This deficient practice had the potential to lead to the patient experiencing unrelieved pain. A review of Patient 2’s profile indicated a Start of Care (SOC) date of 9/13/2022 with a primary diagnosis of spinal stenosis (condition when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots) of the thoracic (middle section of the spine) and lumbosacral (the area of the spine that makes up the lower back) regions. A review of Patient 2’s Plan of Care (POC) for certification period from 11/12/2022 to 1/10/2023 indicated Skilled Nurse (SN) to visit once a week for one week and twice a week for four weeks for skilled assessment and observation of vital signs (VS, clinical measurements that indicate the state of a patient’s essential body functions including pulse rate, temperature, respiration rate, blood pressure, and pain). The POC indicated SN to perform per visit the patient’s pain status, to assess pain, and to teach patient pain management techniques. An electronic medical record review on 1/10/2023 of Patient 2’s SN visit note dated 12/9/2022 indicated Patient 2 reported pain at a level of 7/10 using the pain scale. The SN visit note indicated Patient 2’s pain regimen included the use of pain medication, oxycodone 10 milligrams (mg, unit of weight) tablet with a frequency of one tablet by mouth four times a day as needed for pain management with the medication being documented as effective. The SN visit noted indicated the pain level “lows down to tolerable state”. During a concurrent interview and electronic record review on 1/12/2023 at 10:03 AM with DPCS of Patient 2’s electronic medical chart, DPCS stated pain re-assessment should include the SN to ask the patient to rate their pain level on a scale of 0-10. DPCS stated the SN visit note indicating the pain level “lows down to tolerable state” is not an accurate pain re-assessment because “tolerable level” does not indicate an accurate pain level. DPCS stated the importance of accurate pain re-assessment is to assess the comfort of the patient, monitor/assess the patient’s condition, and to assess the effectiveness of the pain management therapy. A review of the undated HHA’s policy and procedure (P&P) titled, “Pain Assessment”, the P&P indicated when pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition and will be documented to facilitate regular re-assessment and follow up by clinicians. The P&P indicated when the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible including pain intensity using a rating scale (on a scale of 1-10; 0= no pain, 10=unbearable pain), the pain intensity should include current pain, worst pain, and least pain using the scale and present pain management regimen and effectiveness.