Every finding on record at Abiding Care Services Inc

A recertification survey was conducted on 02/27/2026. The census was: Licensed and Certified Home Health Services: 0; Licensed Home Health Services: 0; Personal Assistance Services: 15. The agency was in compliance with no deficiencies cited.

A recertification survey was conducted on 02/27/2026. The census was: Licensed and Certified Home Health Services: 0; Licensed Home Health Services: 0; Personal Assistance Services: 15. Abbreviations: Abbreviations: DON – director of nurses HHA – home health agency SN – skilled nursing

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: This is a repeated violation cited at G574 on 02/17/2023. Based on record review and interview, the agency failed to ensure the plan of cares included the psychosocial status and patient-specific interventions in two of two records reviewed (Patient 1 and 2) in that: a. In one of two records reviewed (Patient 1), the plan of care did not include patient-specific interventions and vital sign parameters to report to the doctor/ordering practitioner. b. In one of two records reviewed (Patient 2), the plan of care did not include the psychosocial status; patient-specific interventions; vital sign and weight parameters to report to the physician/ordering practitioner. These failures placed patients in jeopardy of harm from agency staff who could not address the patient’s risk factors and types of services needed for appropriate care and placed them at risk of a declining health status and complications. Findings included: According to the Cleveland Clinic, last updated 08/07/2024 (retrieved from https://my.clevelandclinic.org/health/treatments/prosthetic-leg): Possible complications of using an artificial leg include rubbing/irritation/damage to the skin and development of pressure sores/wounds. According to the Cleveland Clinic, last updated 05/10/2022 (retrieved from https://my.clevelandclinic.org/health/diseases/22962-hypervolemia): How can I prevent fluid overload: eat a low salt diet; monitor the amount of daily fluid consumption; keep track of how much you weigh. The Administrator stated on 02/23/2026 at 1:15 PM during an interview with Surveyor 1 that the Alternate Administrator/DON was responsible for ensuring the plan of cares included all required elements. Patient 1: Record review of the electronic and paper medical record included a plan of care dated 02/20/2024 to 04/19/2024 with a start of care date of 02/20/2024. The physician ordered the nurse to visit the patient once every nine weeks. The plan of care included a diagnosis of heart disease, low heart rate, joint pain, and lung disease. The plan of care included the patient had an amputation and required the use of an artificial leg. Section 21, orders for discipline and treatments on the plan of care read, “SN: 1 visit(s), every (sic) for 9 week(s) Pain status: patient will continue to take pain medication as prescribed.” The plan of care did not include any patient-specific orders or interventions. The plan of care did not include orders for the nurse to assess the amputation stump where the artificial leg attached for signs and symptoms of skin irritation/breakdown or wound development or out of range vital sign parameters to report to the physician/ordering practitioner for blood pressure, heart rate, blood oxygen level, respiratory rate, and temperature. Surveyor 1 conducted an interview with the Alternate Administrator/DON on 02/27/2026 at 12:30 PM, the surveyor presented the findings and asked why all required elements were not included in the plan of care and agency policy followed. Alternate Administrator/DON stated she was confused because she remembered charting some of the things that were missing or why they would not be included in the plan of care. The Alternate Administrator/DON further stated the agency had changed charting systems and the people with the new system helped her transfer information from the old system to the new system and maybe some of the information did not transfer into the new system. Surveyor 1 conducted an interview with the Administrator on 02/27/2026 at 2:20 PM, the surveyor presented the findings and asked why all required elements were not included in the plan of care and agency policy was not followed. The Administrator stated the agency had a problem with their software vendor archiving agency’s documents. Patient 2: Record review of the electronic and paper medical record included a plan of care dated 04/11/2023 to 06/09/2023 with a start of care date of 12/12/2022. The physician ordered the nurse to visit the patient once every nine weeks. The plan of care included a diagnosis of fluid overload (the body retains too much fluid, leading to swelling, high blood pressure, and potential organ complications), lung disease, high blood pressure and hip pain. The plan of care included a section titled, “Psychosocial”, that included sleep/rest: adequate. The plan of care did not include interpersonal relationships in the immediate family, financial status, homemaker/household needs, vocational rehabilitation needs, family social problems and transportation needs. The plan of care did not include out of range parameters to report to the physician/ordering practitioner for the heart rate, blood oxygen level, respiratory rate, temperature, weights. The plan of care did not include orders for the nurse to monitor the patients weight for signs and symptoms of fluid overload. Surveyor 2 conducted an interview with the Alternate Administrator/DON on 02/27/2026 at 12:37 PM, the surveyor presented the findings and asked why the psychosocial status was not included in the plan of care. The Alternate Administrator/DON stated she did not know why that information was missing. Surveyor 2 conducted an interview with the Alternate Administrator/DON on 02/27/2026 at 12:41 PM, the surveyor presented the findings and asked why patient-specific interventions; and vital sign and weight parameters to report to the physician/ordering practitioner were not included in the plan of care. The Alternate Administrator/DON stated there was a place [in the patient’s electronic record] where she typically charted that information and it could be wrong information pulled up on the patient form. Agency policy titled, “Plan of Care (Plan of Treatment)” undated, read in part, “…The plan of care must be established and authorized in writing by the physician based on an evaluation of the patient's immediate and long term needs. The HHA staff… shall have a substantial role in assessing patient needs, consulting with the physician, and helping to develop the overall plan of care…”

A recertification survey was conducted on 2/13/2023. The census was 20. 2 Licensed and Certified patients, O Licensed Home Health patients, and 18 Personal Assistance Services patients. An exit conference was conducted on 2/17/2023. The agency was in compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 2/13/2023. The census was 20. 2 Licensed and Certified patients, O Licensed Home Health patients, and 18 Personal Assistance Services patients. An exit conference was conducted on 2/17/2023. Abbreviations: QAPI- Quality Assurance Performance Improvement QI – Quality Improvement QM – Quality Management POC – Plan of care RN – Registered Nurse LVN – Licensed Vocational Nurse

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include a description of the patient's risk for emergency department visits and hospital re-admission on the Plan of Care for 2 (Patient 1 and 2) of 2 active patients. The failure to include all the required information on the plan of care meant the patients were subjected to an increased risk for emergency care and hospitalization when the agency failed to identify and mitigate the patients’ risk factors. A review of the Plan of Care for Patient 1 revealed a start of care of 12/12/2022 and a certification period of 12/12/22 to 02/09/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. A review of the Plan of Care for Patient 2 also revealed a start of care of 12/12/2022 and a certification period of 12/12/22 to 02/09/2023. A review of the entire plan of care failed to find a description of the patient’s risks for emergency room visits and hospitalization. An interview was conducted with the Administrator and the Director of Nurses on 2/17/19 at 1:45 PM. The surveyor reviewed the findings from the record reviews and asked why the plans of care failed to include the patient’s risks for emergency room visits and hospitalization. The Director of Nurses said she did not know why it wasn’t there. The DON stated she understood it should be on the plans of care. The surveyor reviewed the finding that the agency policy did not contain a requirement for a description of each patient’s risks for emergency room visits and hospitalization, as required by the regulation. The Administrator stated they had just purchased this new policy and procedure manual. A review of the agency policy titled Plan of Care with no date read in part: Services will be provided in accordance with a Plan of Care based on the patient’s diagnoses and assessment of immediate and long-range needs and resources…. All program services will comply with regulatory requirements and the Agency’s policies and procedures. The surveyor noted the policy did not contain the requirement for a description of the patients risks for emergency room visits and hospitalization.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct performance improvement projects annually for the three-year period of review 2/13/2020 to 02/13/2023. The outcome of the agency’s deficient practice was the agency patients were potentially subjected to substandard care when the agency had not evaluated the care and operations and developed plans to improve performance, and or address any issues that were or could have impacted patient care. The surveyor requested the QAPI program documents during the entrance conference on 2/13/2023. A review of the QAPI documents provided by the Administrator on 2/13/2023 at 1:50 PM revealed any evidence of performance improvement projects. A review of the entire Quality Management (QM) Plan provided by the Administrator revealed no plan for performance improvement projects for 2020, 2021, and 2022. An interview was conducted with the Administrator and the Supervising Nurse on 2/17/2023 at 12:39 PM. The surveyor reviewed the findings of the review of the QAPI documents and asked about the lack of Performance Improvement Projects. The Supervising Nurse stated: “We don’t have anything specific.” The surveyor asked for the documentation of the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. The Administrator stated they did not know they should be including this as part of the quality improvement activities. The Administrator stated they had just purchased a new policy and procedures manual. A review of the Agency policy and procedures for the licensed and certified services revealed a policy titled: “Quality Management (QM) Plan” numbered 4.1 with no date that read in part: “Policy - The Agency develops implements and maintains an effective, on-going, organization wide quality assessment and performance management program. The Agency must measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the organization to assess processes of care, efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. Purpose – To continuously collect and analyze data to improve the Agency’s performance of patient care and other processes, specifically as follows: … Conform to all applicable federal / state rules / regulations as well as home care standards…Administrative responsibility for the QM plan is delegated to the Administrator, who, in turn, assigns certain QM activities and instituting appropriate information systems (manual and/or computer) for collecting and analyzing data. The Administrator is responsible for appointing the Quality Improvement (QI) Coordinator and assigning staff to the QM team. The role of QI Coordinator will be the responsibility of the Director of Clinical Services…”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview the Administrator failed to be responsible for all day-to-day operations of the agency and failed to be responsible for implementing and supervising the administrative policies of the agency and administratively supervising the provision of all services. The Administrator failed to ensure that the policies for QAPI, Performance Evaluations, Professional License Verification, and Personnel Records were implemented. The outcome was the patients and staff were subjected to risk of poor or unsafe care when the quality of services was not being evaluated, personnel files failed to contain evidence of professional licensure verifications, and annual performance evaluations were not provided to aide staff in improving their care. QAPI A review of the QAPI documents provided by the Administrator on 2/13/2023 at 1:50 PM revealed any evidence of performance improvement projects. A review of the entire Quality Management (QM) Plan provided by the Administrator revealed no plan for performance improvement projects for 2020, 2021, and 2022. An interview was conducted with the Administrator and the Supervising Nurse on 2/17/2023 at 12:39 PM. The surveyor reviewed the findings of the review of the QAPI documents and asked about the lack of Performance Improvement Projects. The Supervising Nurse stated: “We don’t have anything specific.” The surveyor asked for the documentation of the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. The Administrator stated they did not know they should be including this as part of the quality improvement activities. The Administrator stated they had just purchased a new policy and procedures manual. PERSONNEL POLICY / PERFORMANCE EVALUATIONS Review of personnel file for Employee A revealed a hire date of 07/15/2019 for the position of Administrator / Licensed Vocational Nurse. The personnel file did not contain any annual performance evaluations due by 07/15/2020, 07/15/2021, and 07/15/2022. Review of personnel file for Employee B revealed a hire date of 07/15/2019 for the position of Registered Nurse / Supervising Nurse Alternate Administrator. The personnel file did not contain any annual performance evaluations due by 07/15/2020, 07/15/2021, and 07/15/2022. Review of personnel file for Employee C revealed a hire date of 08/10/2019 for the position of Registered Nurse / Alternate Supervising Nurse. The personnel file did not contain any annual performance evaluations due by 08/10/2020, 08/10/2021, and 08/10/2022. Review of personnel file for Employee D revealed a hire date of 12/22/2021 for the position of Home Health Aide. The personnel file did not contain any annual performance evaluations due by 12/22/2022. Review of personnel file for Employee E revealed a hire date of 01/16/2020 for the position of Attendant. The personnel file did not contain annual performance evaluations due by 01/16/2021. Employee E stopped working for the agency 04/18/2021. Review of personnel file for Employee F revealed a hire date of 02/15/2015 for the position of Attendant. The personnel file did not contain any annual performance evaluations after 02/15/2017. Annual performance evaluations due by 02/15/2020, 07/15/2021, and 07/15/2022. Review of personnel file for Employee G revealed a hire date of 10/04/2017 for the position of Attendant. The personnel file did not contain any annual performance evaluations due by 10/04/2020, 10/04/2021, and 10/04/2022. Review of personnel file for Employee H revealed a hire date of 10/09/2018 for the position of Attendant. The personnel file did not contain any annual performance evaluations due by 10/09/2020, 10/09/2021, and 10/09/2022. An interview was conducted with the Administrator on 02/17/23 at approximately 2:35 PM. The surveyor reviewed the findings from the review of the personnel files. The surveyor asked about the lack of performance evaluations. The Administrator stated: “We have not done it, just check offs and haven’t documented (evaluations).” This citation was previously cited during the survey that ended 12/11/2019. PERSONNEL POLICY / Verification of Professional Licensure Review of personnel file for Employee A revealed a hire date of 07/15/2019 for the position of Administrator / Licensed Vocational Nurse. The personnel file contained verification of a nursing license that expired on 11/30/2021. The personnel file did not contain evidence of a current professional license for the nurse who made weekly visits to the agency patients. Review of personnel file for Employee B revealed a hire date of 07/15/2019 for the positions of Registered Nurse / Supervising Nurse / Alternate Administrator. The personnel file contained verification of a nursing license that expired on 11/30/2021. The personnel file did not contain evidence of a current professional license for the nurse who conducted OASIS assessments and made weekly visits to agency patients. Review of personnel file for Employee C revealed a hire date of 08/10/2019 for the position of Registered Nurse / Alternate Supervising Nurse. The personnel file contained verification of a nursing license that expired on 06/30/2020. The personnel file did not contain evidence of a current professional license for the nurse who was the Alternate Supervising Nurse for the agency. There were no other licensed staff employed by the agency at the time of the survey according to the list of employees provided by the Administrator. An interview was conducted with the Administrator on 02/17/23 at approximately 2:30 PM. The surveyor reviewed the findings from the review of the personnel files. The surveyor asked about the lack of current licensure verifications for Employees A, B, and C. The Administrator stated: “We have renewed (nursing licenses) and haven’t made copies.” The surveyor asked if the agency had a system or method for tracking when licenses would expire. The Administrator stated that the new electronic medical record system that the agency was transitioning to in February 2023 had a system to track licenses. The surveyor requested copies of the current licenses. The Administrator emailed copies of the current licensure verifications for Employees A, B and C to the surveyor after the end of the survey on Tuesday 02/21/2023 at 9:32 AM. Agency policy titled: “Administrator: Defined” numbered 5.10 with no date read in part: “Policy- There is an individual who is designated as responsible for the overall operation and services of the Agency…The Administrator of the Agency organizes and directs the Agency’s ongoing functions and has the overall responsibility to ensure the following: Ensures the Agency’s skilled health services are in compliance with all applicable regulations…and federal, state, and local laws … Ensures the maintenance of appropriate personnel, financial and administrative records and all policies and procedures of the agency. Employs qualified personnel in accordance with written job descriptions and ensures adequate staff education, supervision and evaluations… Directing and monitoring organizational Quality Management activities…”” Agency policy titled: “Personnel Records” numbered 7.9 with no date read in part: “Policy – Personnel files will be established and maintained for all staff…. Procedure – The personnel record for a employee will include: … Validation of performance evaluation at completion of 90 day probationary period… Validation of annual performance evaluation. – Evaluation will include joint home visit with supervisor/peer for all patient care staff… Current license, registration, or certification as applicable…” Agency policy titled: “License, Registration or Certification Requirements” numbered 7.8 with no date read in part: “To provide a mechanism whereby the Agency assures that all personnel license(s) or certification(s) are kept current and are documented in Agency records… When current licensure… are required by law and/or regulation to practice a profession, the Agency verifies such credentials with the primary source at the time of hire, annually and prior to or upon expiration of credentials. Primary source verification will occur through the applicable state board of practice…All such verification will be documented …” A review of the Agency policy and procedures for the licensed and certified services revealed a policy titled: “Quality Management (QM) Plan” numbered 4.1 with no date that read in part: “Policy - The Agency develops implements and maintains an effective, on-going, organization wide quality assessment and performance management program. The Agency must measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the organization to assess processes of care, efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. Purpose – To continuously collect and analyze data to improve the Agency’s performance of patient care and other processes, specifically as follows: … Conform to all applicable federal / state rules / regulations as well as home care standards…Administrative responsibility for the QM plan is delegated to the Administrator, who, in turn, assigns certain QM activities and instituting appropriate information systems (manual and/or computer) for collecting and analyzing data. The Administrator is responsible for appointing the Quality Improvement (QI) Coordinator and assigning staff to the QM team. The role of QI Coordinator will be the responsibility of the Director of Clinical Services…”