Every finding on record at 4 Your Peace of Mind, LLC

Unannounced visits were concluded at 4 Your Peace of Mind, LLC on 5/29/24 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded on 5/29/24 at 4 Your Peace of Mind, LLC for the purpose of recertification. Standard-level deficiencies were identified.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interviews with agency personnel for two of four patients (Patient #2 and #4), requiring medication management, the agency licensed personnel failed to follow agency policies for medication documentation in the electronic clinical record and medication reconciliation. The findings include: Patient #4 had a start of care date of 7/25/23 and diagnoses that included type II diabetes mellitus and hyperlipidemia. Physician's orders for the certification periods of 3/21/24 to 7/18/24 included nursing services two times a day for medication administration and assessments and home health aide services up to fourteen hours a week for assistance with personal care. Interview and review of the twice daily nursing notes from 4/01/24 to 5/27/24 (one hundred twelve medication administration visits) with the Administrator and RN #1 on 5/29/24 at 11 AM failed to identify documentation of the medications administered in the electronic Medication Administration Record/MAR in accordance with agency policies. Review of agency policy for Medication Administration Record directed that MAR’s would need to be filled out for daily, twice daily and three times daily medication administrations. The MAR shall reflect the electronic medication profile in the electronic record and all medications administered should be signed off by the administering nurse via an initial/the electronic signature for every medication given at each patient visit. Patient #2 had a start of care date of 12/29/2023 with diagnoses that included schizophrenia, dementia, bipolar disorder, anxiety, delusional disorder, benign prostatic hyperplasia, and pain. The physician’s orders for the certification periods of 04/27/2024 to 06/25/2024 included nursing services five times per week for eight weeks for assessments, daily medication administration and pre-pouring of the evening medications for spouse to administer. Review of Patient #2’s medication administration record (MAR) dated 04/23/2024, identified Patient #2 was prescribed Hydroxyzine 50 milligrams (mg) one tab every six hours as needed for anxiety and Olanzapine 10 mg (antimanic medication) one tab every night at bedtime. Patient #2’s medication administration record within the electronic medical record indicated the Patient was administered Hydroxyzine 50 mg on 04/29/2024, 04/30/2024, 05/02/2024, 05/22/2024, and 05/27/2024. Additionally, Patient #2 was administered Olanzapine on 04/29/2024, 04/30/2024, 05/02/2024, 05/03/2024, 05/06/2024, 05/07/2024, 05/08/2024, 05/09/2024, 05/10/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/20/2024, 05/21/2024, 05/22/2024, 05/23/2024, 05/24/2024 and 05/27/2025. During a nursing visit on 05/28/2024 for Patient #2 with Licensed Practical Nurse (LPN) #1, the Patient’s responsible caregiver identified Hydroxyzine and Olanzapine were discontinued over a month ago. Review of a care coordination note dated 05/28/2024, identified LPN #1 contact Patient #2’s primary care physician to identify if the Patient should receive Hydroxyzine and Olanzapine and was awaiting a response. Interview and review of Patient #2’s clinical record with the Administrator on 05/29/2024 at 10:00 AM, failed to identify Patient #2’s medications were reconciled at each nursing visit to ensure an accurate medication profile in accordance with the agency’s Medication Reconciliation policy. Review of the agency’s Medication Reconciliation policy identified the purpose of the policy was to avoid medication errors caused by omission, duplication, and transcription of medication orders. The medication profile would be updated when orders change, or client adds/discontinued. An updated medication profile would be present in the patient’s home or electronic medical record for all staff involved in the care.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of four patients (Patient #4) requiring blood glucose monitoring for a diagnosis of type II diabetes mellitus the agency nurses failed to provide the necessary assessments. The findings include: Patient #4 had a start of care date of 7/25/23 and diagnoses that included type II diabetes mellitus and hyperlipidemia. Physician's orders for the certification periods of 3/21/24 to 7/18/24 included nursing services two times a day for medication administration and assessment of blood glucose testing at every encounter and home health aide services up to fourteen hours a week for assistance with personal care. Interview and review of RN #2’s weekly nursing notes from 3/27/24 to 5/22/24 and LPN #2’s nursing notes dated 5/21/24, 5/24/24 and 5/27/24 with the Administrator and RN #1 on 5/29/24 at 1:30 PM failed to identify blood glucose monitoring during the nursing visits and failed to follow physician’s orders.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on review of clinical records and interview with agency personnel, for three of seven patients (Patients #1, #2 and #7) in the survey sample, the agency failed to provide services in accordance with the physician certified plan of care. The findings include: a. Patient #1 had a start of care date of 12/18/2023 with diagnoses that included type II diabetes mellitus, age related memory loss and high blood pressure. The physician’s orders for the certification period of 04/16/2024 to 06/14/2024 included nursing services ten times per week for nine weeks for assessments, blood glucose monitoring, and twice daily medication administration. i. Interview and review of Patient #1’s clinical record with the Administrator on 05/29/2024 at 11:30 AM, failed to identify skilled nursing visits were conducted on 04/25/2024, 04/26/2024, and 04/27/2024 in accordance with Patient #1’s plan of care and failed to identify the Patient’s physician was notified of the missed visits. b. Patient #2 had a start of care date of 12/29/2023 with diagnoses that included schizophrenia, dementia, bipolar disorder, anxiety, delusional disorder, benign prostatic hyperplasia, and pain. The physician’s orders for the certification periods of 04/27/2024 to 06/25/2024 included nursing services five times per week for eight weeks for assessments, daily medication administration and pre-pouring of the evening medications for spouse to administer. ii. Interview and review of Patient #2’s clinical record with the Administrator on 05/29/2024 at 11:32 AM, failed to identify a skilled nursing visit was conducted on 05/13/2024 in accordance with Patient #2’s plan of care and failed to identify the Patient’s physician was notified of the missed visit. c. Patient #7 had a start of care date of 12/29/2023 with diagnoses that included type II diabetes mellitus, depression, hypertension, peripheral vascular disease, high cholesterol, and osteoarthritis. The physician’s orders for the certification period of 02/27/2024 to 04/26/2024 included nursing once per week for assessments. iii. Interview and review of Patient #7’s clinical record with the Administrator on 05/29/2024 at 11:40 AM, failed to identify a skilled nursing visit was conducted for the week of 03/03/2024 in accordance with Patient #7’s plan of care and failed to identify the Patient’s physician was notified of the missed visit. Review of the agency’s Missed Visit policy identified if a patient’s visit cannot be made and the agency has not reached the patient, the physician would be notified by fax/telephone that the visit was missed and why. The process and outcome would be documented in the patient’s clinical record.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for two of seven patients (Patient’s #1 and #4) in the survey sample, the agency Registered Nurse/RN failed to supervise the care provided by the Licensed Practical Nurse/LPN. The findings include: Patient #4 had a start of care date of 7/25/23 and diagnoses that included type II diabetes mellitus and hyperlipidemia. Physician's orders for the certification periods of 3/21/24 to 7/18/24 included nursing services two times a day for medication administration and assessments and home health aide services up to fourteen hours a week for assistance with personal care. Interview and review of RN #2’s weekly nursing notes from 3/27/24 to 5/22/24 (eight visits) with the Administrator on 5/28/24 at 12:50 PM identified that RN #2 conducted the weekly visits on Wednesdays, LPN #2 conducted the other twice daily visits weekly and failed to identify documentation by RN #2 of a supervisory visit to evaluate the care/services provided by the LPN. Review of agency policy for Clinical and Direct Care Supervisions directed the RN will make a supervisory visit to the patient’s home at least every thirty days with or without the LPN present to evaluate the care/services provided by the LPN. Patient #1 had a start of care date of 12/18/2023 with diagnoses that included type II diabetes mellitus, age related memory loss and high blood pressure. The physician’s orders for the certification period of 02/16/2024 to 04/15/2024 included nursing services ten times per week for nine weeks for assessments, blood glucose monitoring, and twice daily medication administration. Interview and review of the Patient #1’s clinical record from 02/16/2024 to 04/15/2024 with the Administrator on 05/29/2024 at 10:40 AM, failed to identify a monthly Licensed Practical Nurse (LPN) supervision was conducted by a Registered Nurse (RN) in accordance with the agency’s policy to evaluate the care/services provided by the LPN.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for one of one patient (Patient #4) who received skilled nursing services along with home health aide services, the agency RN failed to provide onsite supervisory visits no less frequently than every 14 days. The findings include: Patient #4 had a start of care date of 7/25/23 and diagnoses that included type II diabetes mellitus and hyperlipidemia. Physician's orders for the certification periods of 3/21/24 to 7/18/24 included nursing services two times a day for medication administration and assessments and home health aide services up to fourteen hours a week for assistance with personal care. Interview and review of the clinical record from 3/21/24 to 5/22/24 (nine weeks) with the Administrator on 5/28/24 at 1 PM identified that the home health aide visited three times weekly, RN #2 conducted weekly visits on Wednesdays, and failed to identify documentation by RN #2 of a supervisory visit every fourteen days to verify that the plan of treatment, plan of care or plan for personal care services is being followed appropriately by the home health aide. Review of the agency policy for Clinical and Direct Care Supervisions directed that home health aides supervision visits for patient s receiving skilled home health agency services and aide services must be performed by an RN or delegated Physical Therapist/Occupational Therapist and shall occur no less frequently than every fourteen days and shall include verification that the plan of treatment, plan of care or plan for personal care services is being followed appropriately.