Every finding on record at Aau Home Health Care LLC

Substantial Allegation Survey Substantial Allegation OH00120448 No deficiencies were cited related to allegations contained in substantial allegation OH00120448 completed on 03/09/21; however, the following deficiencies are cited. AAU Home Health Care LLC 369140, was in substantial compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and medical record review, the agency failed to alert the physician to changes in the patient's condition or needs that suggest that outcomes are not being achieved for one of four patients (Patient #1). The agency census was 105 patients. Findings include: The medical record review for Patient #1 was completed on 03/09/21. The medical record review revealed the patient's care began with the agency on 05/15/2020. The medical record review revealed a plan of care for the certification period beginning 01/10/21 with diagnoses of multiple sclerosis, unspecified mood [affective] disorder, low back pain, nicotine dependence, legal blindness, and unspecified optic atrophy. The patient was incontinent of bowel and bladder. The agency was directed to provide weekly skilled nurse visits to assess vital signs, provide a skilled assessment, and review and reconcile the medications. A review of the skilled nurse visit notes was completed on 03/09/21. The review of the skilled nurse visit note dated 01/15/21 stated, "Patient's mother is concerned about him not eating very well." The review of the skilled nurse visit note dated 01/23/21 stated, "Continued concerned from family about him not wanting to eat very well." The review of the skilled nurse visit note dated 01/30/21 stated, "Continued concerned from family about him not wanting to eat very well." The review of the skilled nurse visit note dated 02/13/21 stated, "Continued concerned from family about him not wanting to eat very well." The medical record review did not reveal any documentation the physician was contacted about these concerns. On 03/04/21 in an interview, Staff P confirmed the patient did not eat much. He said he did not converse with the physician regarding the patient's appetite or the family's concern for his not eating very well.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and medical record review, the agency failed to ensure home health aides provided services that were included in the plan of care for one of four sampled patients (Patient #1). The agency census was 105 patients. Findings include: The medical record review for Patient #1 was completed on 03/09/21. The medical record review revealed the patient's care began with the agency on 05/15/2020. The medical record review revealed a plan of care for the certification period beginning 01/10/21 with diagnoses of multiple sclerosis, unspecified mood [affective] disorder, low back pain, nicotine dependence, legal blindness, and unspecified optic atrophy. The patient was incontinent of bowel and bladder. The review revealed the agency was directed to provide 60 hours a week of home health aide visits. The medical record review revealed a home health aide care plan dated 01/08/21 that directed the home health aide to provide services including a shower or bath, shave, incontinence care, and light housekeeping. The medical record review did not reveal any home health aide visit notes since 01/12/21. A review of the agency's timesheet procedures was completed on 03/09/21. The review revealed, "Timesheets are due in the agency's office by 12:00 noon every Monday." On 03/04/21 at 3:23 PM in an interview, Staff O said although he could validate based on electronic time punches that the home health aide was providing visits, he confirmed there were no home health aide visit notes since 01/12/21 to show what the aide did during her visits.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on interview and medical record review, the agency failed to ensure home health aides reported changes in the patient's condition to a registered nurse for one of four sampled patients (Patient #1). The agency census was 105 patients. Findings include: The medical record review for Patient #1 was completed on 03/09/21. The medical record review revealed the patient's care began with the agency on 05/15/2020. The medical record review revealed a plan of care for the certification period beginning 01/10/21 with diagnoses of multiple sclerosis, unspecified mood [affective] disorder, low back pain, nicotine dependence, legal blindness, and unspecified optic atrophy. The patient was incontinent of bowel and bladder. The review revealed the agency was directed to provide 60 hours a week of home health aide visits. The medical record review did not reveal any home health aide visit notes since 01/12/21. On 03/04/21 at 3:51 PM in an interview, Staff O said based on electronic time punches, the home health aide, Staff A, last cared for the patient 02/13/21. He said Staff P then attempted a skilled nurse visit on 02/19/21 but no one answered the door or the telephone. He said he notified the case manager and no one called him back. He said management learned the patient was admitted to the hospital because the hospital called them on 02/20/21 to notify them they had admitted the patient to the hospital. Multiple attempts were made to interview the home health aide, Staff A. On 03/08/21 at 1:30 PM in an interview, Staff O said the home health aide would not answer the phone, and when staff went to the home on 03/04/21 and again on 03/08/21 no one was there to answer the door. A review of the home health aide's job description was completed on 03/09/21. The review revealed the home health aide was to adhere to established agency policies and procedures and report "changes in the client's condition and needs to the appropriate supervisor."