Every finding on record at A-Cure Healthcare Solutions, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 04/25/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 04/25/24. Standard level deficiencies cited. Abbreviations: SOC = Start of Care POC = Plan of Care Pt. = Patient Pts. = Patients

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. 1. The Agency Pt. admission folder was reviewed on 04/22/24. The folder lacked information identifying the Clinical Manager's name and contact information. 2. The clinical records of the following Pts. were reviewed from 4/22/24 to 4/23/24: Pt. #1. SOC 01/21/24. Pt. #2. SOC 03/21/24. Pt. #3. SOC 03/15/24. Pt. #4. SOC 03/26/24. Pt. #5. SOC 03/09/24. Pt. #6. SOC 10/12/23. Pt. #7. SOC 02/21/23. The clinical records reviewed lacked information identifying the Clinical Manager's name and contact information. 3. The following home visits were conducted on 04/23/24 from 9:00 AM to 3:30 PM. Pt. #1. SOC 01/21/24. Pt. #2. SOC 03/21/24. Pt. #3. SOC 03/15/24. 4. During the home visits, on 04/23/24 from 9:00 AM to 2:30 PM, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Clinical Manager. 5. During staff interview with the Administrator and Clinical Supervisor on 04/25/24 at 12:00 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on the clinical records review, policy review and staff interview, it was determined in 4 of 7 (Pts. #2, 3, 5 and 6) records reviewed, the clinical records were not completed as required. 3. Patient #5 was admitted to the Home Health Services on 03/09/24 with the Diagnosis of: Unspecified Severe Protein-Calorie Malnutrition. The clinical record was reviewed on 04/23/24. The clinical record included an incomplete “Flu/Pneumonia Vaccine Checklist” form. The form lacked the information regarding the patient’s responses. The record also included late entries for the Physical therapy visit notes dated 04/02/24, 04/08/24 and 04/16/24 (which were submitted 04/24/24). 4. Patient #6 was admitted to the Home Health Services on 01/01/24 with the Diagnosis of: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Unspecified. The discharged clinical record was reviewed on 04/23/24 The discharged clinical record included an incomplete “Flu/Pneumonia Vaccine Checklist” form. The form lacked the information regarding the patient’s responses. The record also included late entries for the Physical therapy visit notes dated 04/04/24, and 04/11/24 (which were submitted 04/24/24). 5. Patient #7 was admitted to the Home Health Services on 02/21/23 with the Diagnosis of: Complex Regional Pain Syndrome Right Lower Limb. The discharged clinical record was reviewed on 04/23/24. The discharged clinical record lacked the Physical therapy missed visit notes dated for May 2023. During the interview with the Clinical Supervisor on 04/24/23 at 10:50 AM, it was stated that the notes were in “Therapy Boss” and he will have them incorporated into the Agency’s electronic records. 6. The Agency’s Policy titled “Timely Submission of Patient Documentation” was reviewed on 04/24/24 at 12:30 PM. The policy included “…PROCEDURE … 2. Itineraries, with all visit reports attached, must be submitted the following week or seven (7) business days…from the date of the visit. The discharge medical record is complete within 45 days of discharge.” 7.The findings were confirmed, during the interviews with the Clinical Supervisor and Administrator, on 04/24/24 between 10:00 AM and 11:30 AM. 1. Pt. #2 was admitted to Home Health Services on 03/21/24 with the primary Diagnosis of Non-ST elevation (NSTEMI) myocardial infarction. The clinical record was reviewed on 04/22/24. The record included “Flu/Pneumonia Vaccine Checklist” which was incomplete. The form lacked the information regarding the patient’s responses. 2. Pt. #3 was admitted to Home Health Services on 03/15/24 with the primary Diagnosis of Encounter for removal of surgical wound dressing. The clinical record was reviewed on 04/23/24. The clinical record included “Flu/Pneumonia Vaccine Checklist” which was incomplete. The form lacked the information regarding the patient’s responses.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 04/30/21. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: # =Number E = Employee mcg =Microgram mg = Milligram POC = Plan of Care Pt./Pts. = Patient/Patients SN = Skilled Nurse SOC = Start of Care .

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: . A. Based on a review of clinical records and Staff interview, it was determined that the Agency failed to ensure the Staff provide care and/or service, as specified on the POC. This was found in 4 of 7 (Pts. #1, 3, 7 and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 12/10/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Other Specified Complication. The clinical record was reviewed on 04/27/21 at 12:30 PM. The record contained the POC for the certification period of 02/08/21 to 04/08/21 requiring: "...SN to instruct patient/ caregiver on bladder training program..." The weekly SN visit notes from 02/11/21 to 04/01/21, and the recertification comprehensive assessment completed by the SN and dated 04/08/21 lacked documentation the SN instructed the Pt./caregiver on bladder training. 2. Pt. #3. SOC 01/15/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy without Macular Edema. The clinical record was reviewed on 04/28/21 at 10:40 AM. The record contained the POC for the certification period of 01/15/21 to 03/15/21 requiring: "...SN to instruct patient/ caregiver on bladder training program..." The weekly SN visit notes from 01/23/21 03/05/21 and the recertification comprehensive assessment completed by the SN and dated 03/13/21, lacked documentation the SN instructed the Pt./caregiver on bladder training. 3. Pt. #7. SOC 07/21/20. Primary Diagnosis: Other Specified Arthritis Multiple Sites. The clinical record was on 04/28/21 at 11:50 AM. The record contained the POC for the certification period of 11/18/20 to 01/16/21 requiring: "...SN to instruct Patient/ Caregiver on bladder training program..." The weekly SN visit notes from 11/24/20 to 01/05/21 and the discharge comprehensive assessment completed by the SN and dated 01/12/21 lacked documentation the SN instructed the Pt./Caregiver on bladder training. 4. Pt. #5 SOC 03/14/21 Diagnoses: Pressure Ulcer Right Buttock Stage 2 and Atrial Fibrillation. The clinical record was reviewed on 04/28/21 at 2:00 PM. The POC dated 03/14/21 required the SN to notify the Physician if the heart rate was below 60. The SN visit notes included a heart rate of 56 on 03/23/21 and a heart rate of 54 on 04/13/21. The Physician was not notified as ordered. The same POC also required the SN to instruct the Patient/Caregiver on "bladder training program". The weekly SN visit notes dated 03/14/21 to 04/26/21 lacked documentation the SN instructed the Pt./Caregiver on bladder training. 5. The above findings were confirmed during the interviews on 04/28/21 at 2:00 PM and on 04/29/21 at 10:00 AM, with the Administrator and Director of Nursing.

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: . A. Based on a review of clinical records, observation and interview during home visits, Agency policy review and Staff interview, it was determined the Agency failed to ensure that medications contained in the clinical record were accurate. This was found in 1 of 3 (Pts. #1 ) home visits conducted. Findings include: 1. Pt. #1. SOC 12/10/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Other Specified Complication. The clinical record was reviewed on 04/27/21 at 12:30 PM. The record contained the "Medication Profile" form completed by the SN for the certification period effective 04/09/21. A home visit was conducted with E#8 on 04/27/21 at 1:45 PM, medications were observed and an interview was conducted with the Pt. During the home visit, the following medications were observed: Vitamin B12 1000 mcg per tablet 1 tablet daily, Pt. stated the Vitamin B 12 had been taken for about 8 months; Magnesium 250 mg per tablet 1 tablet daily, Pt. stated the Magnesium had been taken for about 6 months; and Cranberry plus Vitamin C 8400 mg per softgel takes, 1 to 2 softgels every day, Pt. stated the Cranberry plus Vitamin C had been taken for the past 2 to 3 months. As of 04/27/21, "Medication Profile" effective 04/09/21 lacked Vitamin B12, Magnesium and Cranberry plus Vitamin C. During the same interview on 04/27/21, the Pt. stated the SN had observed all the medications listed above. 2. The Agency's policy titled "Medication Reconciliation" was reviewed on 04/29/21 at 10:00 AM. The policy required "....2. Medication ordered while the patient is recieving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication...". 3. The above findings were confirmed during the interviews on 04/28/21 at 2:00 PM and on 04/29/21 at 10:00 AM, with the Administrator and Director of Nursing.