Every finding on record at Abiding Home Health LLC

A recertification survey entrance conference was conducted on 08/15/2023 at 09:40 a.m. with the Administrator. Census: Licensed and Certified: 49 Licensed Home Health: 71 An exit conference was conducted on 08/18/2023 at 11:55 a.m. with the Administrator. The preliminary findings were discussed. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and incident investigation survey entrance conference was conducted on 08/15/2023 at 09:40 a.m. with the Administrator. Incident #423755 Census: Licensed and Certified: 49 Licensed Home Health: 71 Acronyms: POC - Plan of Care SOC - Start of Care mg - milligrams PTA - Physical Therapy Assistant OT - Occupational Therapist PT - Physical Therapist LVN - Licensed Vocational Nurse RN - Registered Nurse An exit conference was conducted on 08/18/2023 at 11:55 a.m. with the Administrator. The preliminary findings were discussed. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information.

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 observation, interview, and record review the agency failed to ensure the patient's clinical record identified all medications that the patient is taking (both prescription and non-prescription) for two of 17 patients (#4, and #7) reviewed for medication in that: 1. Patient #4's current medication profile did not identify Dexamethasone, Methylprednisone, and Omeprazole were no longer being used by the patient. 2. Patient #7's current medication profile did not identify Dexamethasone and Topiramate was no longer being used by the patient. The failure could affect all patients in the agency who received medication and could result in medication error. The findings were: 1. Record review of Patient #4's Plan of Care (certification period 07/20/2023 to 09/17/2023) revealed a SOC date 07/202/2023, diagnoses included Encounter for Other Orthopedic Aftercare, Spinal Stenosis, Lumbar Region with Neurogenic Claudication (muscle pain due to lack of oxygen). During a home visit on 08/16/2023 at 11:00 a.m., Patient #4's current medications were reconciled with the agency's medication profile. Further review of Patient #4's medication revealed Patient #4 was no longer taking Dexamethasone (medication is used to treat certain eye conditions due to inflammation or injury.) 4 mg tablet daily, Methylprednisone DP (used to treat many different inflammatory conditions.) 4 mg tablet daily, and Omeprazole (treat certain stomach and esophagus problems.) 10 mg capsule, one daily. Further interview with Patient #4 revealed she had not taken the medications since the medications ran out. Patient #4 further revealed the PTA that came to visit asked her about doctor's visits but not medication updates. 2. Record review of Patient #7's POC for certification period 08/02/2023 to 09/30/2023 revealed a SOC of 08/02/2023 and diagnoses of Aftercare Following Surgery for Neoplasm (a new and abnormal growth of tissue in some part of the body) and Gastro-Esophagel Reflux Disease. During a home visit on 08/16/2023 at 11:45 a.m., Patient #7's current medications were reconciled with the agency's medication profile. Further review revealed Patient #7 was no longer taking Dexamethasone 2 mg tablet every 12 hours for three days, then one tablet every 12 hours until complete. Patient #7 was no longer taking Topiramate 25 mg and 50 mg tablet two tablets daily. During an interview with Patient #7 at this time revealed she finished the Dexamethasone August 6th and Topiramate before she was admitted to the agency (July 21, 2023). Further interview revealed RN D asked for medication updates and checked if any changes in her medications during home visits. During an interview on 08/18/2023 at 11:05 a.m., RN D revealed he did not go through all of the patient's bottles during home visits, but can do that in the future during supervisory visits. During an interview on 08/18/2023 at 11:23 a.m., the Administrator revealed the nurses were accountable for asking for medication updates, the PTA's don't ask. Further interview revealed The scheduler runs the schedule report every and catches any visits that's not scheduled, the agency reviewed the visits. The nurses should be updating the medication list during visits. Record of the agency's policy and procedure titled ""Medication List and Monitoring (02/20/2023)", read in part, "...Procedure: The agency will maintain a current list of all prescription and over-the-counter (OTC) medications taken by the patient (see medication profile form).

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 agency failed to ensure each patient received home health services that are written in the individualized POC for one of 17 patients (#7 ) reviewed for services in that: Patient #7 did not receive an OT services according to the POC. This failure could affect all patients in the agency that received services and could result in the highest therapeutic outcome not being achieved. The findings were: Record review of Patient #7's POC for certification period 08/02/2023 to 9/30/2023 revealed a SOC on 08/02/2023, diagnoses included Aftercare Following Surgery for Neoplasm (abnormal tissue growth). Further record review of this POC revealed an order for "OT to evaluate for OT services and develop POC..." During a home visit with Patient #7 on 08/16/2023 at 11:45 a.m., Patient #7 revealed she had not received OT services since her SOC. Further interview revealed Patient #7 was not sure why OT services were not provided, but she thought it was due to her insurance not receiving prior authorization. During an interview on 08/17/2023 at 03:10 p.m., the Administrator revealed it took long for contract therapy company to respond to the request. Further interview revealed the contract therapy did not accept the request until the 08/15/2023. Record review of the agency's policy and procedure titled "Plan of Care (03/17/2023)", read in part, "...Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient's specific needs and problems...". Record review of the agency's policy and procedure titled "Implementing Care and Treatment (08/02/2020)", read in part, "...Purpose: To ensure patient care and treatment are provided as identified in the care planning process.."

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 agency failed to ensure the clinical included all interventions including medication administration, treatments, services and response to those services or one of 17 patients (#1) reviewed for services in that: 1. Patient #1's indwelling catheter change was not included in the clinical record. This failure could affect all patients in the agency and could result in an inaccurate account of services received. The findings were: Record review of Patient #1's POC for certification period 06/25/2023 to 08/23/2023 revealed SOC date of 12/27/2022, diagnoses included Encounter for Fitting and Adjustment of Urinary Device. During an interview on 08/18/2023 at 09:49 a.m., Patient #1 revealed her catheter was changed around a week ago or so. During an interview on 8/18/23 at 11:23 a.m., the Administrator revealed Patient #1's indwelling catheter was changed on 08/10/2023 but it was not in her notes. Further interview revealed it's been late seven days and was due to a scheduling process, the scheduler runs the schedule report daily for visits, if it was not scheduled, the visiting staff does not get an alert to document on the visit. Record review of the agency's policy and procedure titled "Clinical Documentation Policy (unknown date)", read in part, "...Procedure: All notes are to be completed on or before 9 a.m. the following day."