Every finding on record at Acacia Home Health Agency

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 4/11/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 04/11/25. Standard level deficiencies cited. Abbreviations: POC = Plans of Care SN = Skilled Nurse MD = Medical Doctor RN = Registered Nurse PT = Physical Therapy MSW = Medical Social Worker SOC = Start of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined in 915 of 1,116 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days, resulting in a warning. Findings include: 1. The Agency's Error Summary report for 03/01/24 to 03/26/25, was reviewed on 04/08/25. The report included an error for 915 of 1,116 of OASIS assessments submitted (81.99 %) were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 04/10/25 at 10:30 AM, the Administrator confirmed the late submissions.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews, Agency policy review, and staff interviews, it was determined that for 2 of 7 (Pts. #5 and #7) clinical records reviewed, the Agency failed to ensure that the RN conducted the initial comprehensive assessment within 48 hours of the referral. Findings include: 1. Pt. #5 was admitted to home health services on 3/7/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 4/8/25. The clinical record contained a Physician Encounter document with the service date of 3/1/25, which received by the Agency on 3/3/25 with orders for SN, PT, Home Health Aide and MSW services. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 2. Pt. #7 was admitted to home health services on 7/19/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/8/25. The clinical record contained a Physician Encounter document with the service date of 7/11/24 with orders for SN and PT (refused). The clinical record lacked an RN initial comprehensive assessment with 48 hours of the referral, or a Physician-ordered SOC date. 3. The Agency policy titled “Client Admission Process” was reviewed on 4/9/25 and required, “7. Each client referred to the agency shall be evaluated by a Registered Nurse/Therapist to determine the immediate care and support the needs of the client…The initial assessment will be completed within 48 hours of referral or within 48 hours of the client’s return home, or on the physician ordered start of care date…” 4. During an interview with the Administrator and Agency Supervisor on 4/9/25 at 10:30 AM, it was stated that the RN should conduct the initial comprehensive assessment within 48 hours of the referral or the Physician-ordered SOC date. During the same interview, the above findings were confirmed.

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 clinical record review and staff interviews, it was determined for 4 of 7 (Pts. #5, #7, #1 and #4) clinical records reviewed, the Agency failed to ensure care was provided as ordered by the Physician as indicated in the POC. 3. Pt. #1 was admitted to home health services on 3/5/25 with diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 4/8/25 and included the POC effective 3/5/25 which required: "Notify Physician of vital sign parameters out of range - Fasting Blood Sugar: greater than (>) 250mg/dl Less than () 300 mg/ dl". The SN visit notes dated 3/12 and 3/19/25 lacked blood sugar assessment. 4. Pt. #4 was admitted to home health services on 11/26/24 with diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 4/8/25 and included the POC effective 01/25/25 to 03/25/25 which required: "Notify Physician of vital sign parameters out of range - Fasting Blood Sugar: greater than (>) 250mg/dl Less than () 300 mg/ dl". The SN visit notes dated 3/05 and 3/11/25 lacked blood sugar assessment. 5. During interviews with the Administrator and Agency Supervisor on 04/09/25 at 11:00 AM and on 04/10/25 at 10:30 AM, the findings of Agency staff not providing care as ordered by the Physicians in the POC were confirmed. Findings include: 1. Pt. #5 was admitted to home health services on 3/7/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 4/7/25 and included the POC effective 3/7/25 which required: “Orders/Treatment… blood glucose monitoring…Nursing Goals: Patient will maintain blood sugar within normal range by the end of episode as evidenced by readings within therapeutic range.” The record also included the initial comprehensive assessment completed by the RN on 3/7/25, which included the documentation, “SN will continue to monitor vital signs and blood sugar every visit and notify MD of any significant findings…” As of 4/9/25, the SN Teaching/Training notes dated 3/11/25, 3/18/25, 3/25/25 and 4/1/25 lacked documentation of blood glucose monitoring results. 2. Pt. #7 was admitted to home health services on 7/19/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/8/25. The record included a POC for the certification period of 7/19/24 to 9/16/24, which was lacked the Physician's signature.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record review, Agency policy review and staff interview, it was determined that for 1 of 1 (Pt. #5) Pts. wherein MSW services were provided, the Agency failed to ensure that concerns are communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. Findings include: 1. Pt. #5 was admitted to home health services on 3/7/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 4/8/25. The MSW note “Social Work Discharge” dated 3/22/25 included the documentation, “Summary/Problem Resolved/Status: A service referral was completed with Pathlight Program at (phone number) to help patient get assistance to help decrease the stressors that is affecting the patient health. MSW also left message for patient’s daughter to contact ADDUS Homecare to be the preferred caretaker at (phone number) …” The clinical record lacked documentation of coordination between the Home Health Agency, the Pt. or Pt. representative and the external organizations related to the referral of services made by the MSW. 2. The Agency policy “Coordination of Client Services” was reviewed on 4/9/25 and required, “To ensure services are coordinated between members of the interdisciplinary team…To establish effective interchange, reporting and coordination of client care does occur. 6. Care conference will be documented on the Care Conference Summary form or in the progress note. A written summary report of services provided and response to care for each client shall be sent to the Physician..." 3. During an interview with the Administrator and Agency Supervisor on 4/9/25 at 11:00 AM, both stated that the clinical record should contain documentation of the follow up and information related to the referral to the above-mentioned program and external organizations for the recommended services. During the same interview, the above finding was confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon, Evening PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist ST = Speech Therapy/Therapist wk = week HHCCN = Home Health Change of Care Notice

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure informed consents contained the disciplines that will provide care and the frequency of visits. This was found in 5 of 7 clinical records reviewed. (Pts. #2, 3, 4, 6, and 7). Findings Include: 1. The following clinical records were reviewed beginning 1/31/22 at 1:00 PM to 2/1/22 at 11:50 AM: Pt. #2 SOC: 11/16/21 Pt. #3 SOC: 1/20//22 Pt. #4 SOC: 12/8/21 Pt. #6 SOC: 7/23/21 Pt. #7 SOC: 3/31/21 The records lacked documentation the above Pts. consented to the disciplines that will provide care and the frequency of visits at the SOC. 2. During an interview with the Administrator and Agency Supervisor on 2/7/22 at 12:00 PM, it was confirmed that the above records lacked documentation the Pts. consented to the disciplines that would be providing care and the frequency of visits at the SOC.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on staff interview, clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure it implemented its policy regarding Pt. screening and administration of influenza and pneumococcal pneumonia vaccines. This was found in 5 of 7 (Pts. #1, 2, 3, 6, and 7) clinical records reviewed. Findings include: 1. During the entrance interview with the Administrator and Agency Supervisor on 1/31/22 at 10:00 AM, the Agency Supervisor stated the RN or PT should ask the Pt. at the SOC about his/her influenza and pneumococcal vaccine status. If the Pt. requests these vaccines, the Pt. is referred to their Primary Physician, and this is documented in the clinical record. 2. Pt. #1 SOC 8/26/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 1/31/21 at 1:45 PM. The record lacked documentation the Pt. was screened for the pneumococcal pneumonia vaccine at the SOC. 3. Pt. #2 SOC 11/16/21. Primary Diagnosis: Multiple Sclerosis. The clinical record was reviewed on 1/31/22 at 1:00 PM. The record lacked documentation the Pt. was screened for the influenza and the pneumococcal pneumonia vaccines at the SOC. 4. Pt. #3 SOC 1/20/22. Primary Diagnosis: Pressure Ulcer of Left Heel, Stage 2. The clinical record was reviewed on 2/1/22 at 9:40 AM. The record lacked documentation the Pt. was screened for the influenza vaccine at the SOC. 5. Pt. #6 SOC 7/23/21. Primary Diagnosis: Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The record lacked documentation the Pt. was screened for the influenza and the pneumococcal pneumonia vaccines at the SOC. 6. Pt. #7 SOC 3/31/21. Primary Diagnosis: Liver Cell Carcinoma. The clinical record was reviewed on 2/1/22 at 11:50 AM. The record lacked documentation the Pt. was screened for the pneumococcal pneumonia vaccine at the SOC. 7. The Agency policy titled “Influenza Vaccination” was reviewed on 1/31/22 at 1:30 PM. The policy required: “…The Agency shall annually administer or arrange for administration of a vaccination against influenza to each Client/Patient…” 8. The Agency policy titled “Pneumoccal Pneumonia Vaccination” was reviewed on 1/31/22 at 1:40 PM. The policy required: “…The Agency shall annually administer or arrange for administration of a pneumococcal pneumonia vaccination…prior to or upon service initiation, unless the Client/Patient refuses the offer for vaccination, or it’s medically contraindicated…” 9. During an interview with the Administrator and Agency Supervisor on 2/7/22 at 12:00 PM, the above findings were confirmed.

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 clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide PT, OT, and ST services as ordered by the Physician. This was found in 2 of 7 (Pts. #4 and 6) clinical records reviewed. Findings include: 1. Pt. #4 SOC 12/8/21. Primary Diagnosis: Malignant Neoplasm of Head of Pancreas. The clinical record was reviewed on 2/1/22 at 10:15 AM. The record contained PT care plan dated 12/11/21, which included the order: “Visit Frequency: 1wk6.” The record lacked documentation a PT visit was conducted on the weeks of: 12/12/21 to 12/18/21, 12/19 to 12/25/21, 12/26/21 to 1/1/21, 1/2/22 to 1/8/22, and 1/9/22 to 1/15/22. The record also lacked documentation the Physician was notified of these missed PT visits. The record also included the OT Care Plan dated 12/11/21, which included the order: “Visit Frequency 1wk7.” The record lacked documentation an OT visit was conducted on the weeks of: 12/19/21 to 12/25/21, 1/2/22 to 1/8/22, and 1/9/22 to 1/15/22. The record also lacked documentation the Physician was notified of these missed 0T visits. 2. Pt. #6 SOC 7/23/21. Primary Diagnosis: Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record was reviewed on 2/1/22 at 11:10 AM. The record contained the POC effective 7/23/21 to 9/20/21, which contained the Physician’s order: “OT Frequency: 1wk1, 2wk3.” The record lacked documentation a second OT visit was conducted on the week of 7/25/21 to 7/31/21. The record also lacked documentation the Physician was notified of these missed 0T visits. The POC also included the Physician’s order: “ST Frequency: 2wk4.” The record lacked documentation of a second ST visit on the weeks of 8/1/21 to 8/7/21, and 8/8/21 to 8/14/21. The record also lacked documentation of any ST visits on the week of 8/15/21 to 8/21/21. The record also lacked documentation the Physician was notified of these missed ST visits. 3. The Agency policy titled “Clinical Documentation” was reviewed on 2/7/22 at 12:40 PM. The policy required: “…Services not provided and the reason for the missed visits will be documented and reported to the Physician using the Missed Visit Contact note…” 4. During an interview with the Administrator and Agency Supervisor on 2/7/22 at 12:00 PM, the Agency Supervisor stated if there is a missed visit that the PT, OT, or ST cannot be make up within the current treatment week, the Physician should be notified, and this is documented in the Patient’s clinical record.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure medical record documents were complete. This was found in 6 of 7 (Pts. #1, 2, 3, 4, 5, and 7) clinical records reviewed. Findings include: 1. Pt. #1 SOC 8/26/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 1/31/21 at 1:45 PM. The record contained a document titled “Patient’s Choice Letter/Beneficiary Elected Transfer Form.” This document was signed by the Pt., but the name of the Home Health Agency Pt. #1 was transferred from and the date were left blank. The record also included a document titled “Notice of Medicare Non-Coverage.” This document was signed by the Pt., but the type of services the Pt. receives, the date these services will end, and the date the document was signed were all left blank. The record also contained a document titled “Home Health Change of Care Notice (HHCCN)” which was signed by the Pt., but the items/services that would change and the reason for the change, as well as the date were left blank. The record also included a document titled “Advance Beneficiary Notice of Non-coverage (ABN),” which was signed by the Pt.; however, the items/services Medicare doesn’t pay for, the estimated cost of these items, which items the Pt. still wants, and the date were all left blank. 2. Pt. #2 SOC 11/16/21. Primary Diagnosis: Multiple Sclerosis. The clinical record was reviewed on 1/31/22 at 1:00 PM. The record contained a document titled “Patient’s Choice Letter/Beneficiary Elected Transfer Form.” This document was signed by the Pt., but the name of the Home Health Agency Pt. #2 was transferred from was left blank. 3. Pt. #3 SOC 1/20/22. Primary Diagnosis: Pressure Ulcer of Left Heel, Stage 2. The clinical record was reviewed on 2/1/22 at 9:40 AM. The record contained a document titled “Patient’s Choice Letter/Beneficiary Elected Transfer Form.” This document was signed by the Pt., but the name of the Home Health Agency Pt. #3 was transferred from was left blank. 4. Pt. #4 SOC 12/8/21. Primary Diagnosis: Malignant Neoplasm of Head of Pancreas. The clinical record was reviewed on 2/1/22 at 10:15 AM. The record contained a document titled “Patient’s Choice Letter/Beneficiary Elected Transfer Form.” This document was signed by the Pt., but the name of the Home Health Agency Pt. #4 was transferred from was left blank. 5. Pt. #5. SOC 10/21/21. Primary Diagnosis: Schizoaffective Disorder, Unspecified. The clinical record was reviewed on 2/1/22 at 10:45 AM. The record contained a document titled “Patient’s Choice Letter/Beneficiary Elected Transfer Form.” This document was signed by the Pt., but the name of the Home Health Agency Pt. #5 was transferred from was left blank. 6. Pt. #7 SOC 3/31/21. Primary Diagnosis: Liver Cell Carcinoma. The clinical record was reviewed on 2/1/22 at 11:50 AM. The record contained a document titled “Patient’s Choice Letter/Beneficiary Elected Transfer Form.” This document was signed by the Pt., but the name of the Home Health Agency Pt. #7 was transferred from was left blank. The record also included a document titled “Notice of Medicare Non-Coverage.” This document was signed by the Pt., but the type of services the Pt. receives, the date these services will end, and the date the document was signed were all left blank. 7. During an interview with the Administrator and Agency Supervisor on 2/7/22 at 12:00 PM, the Agency Supervisor stated all documents within patient clinical records should be given to the Pt. to sign only if and when appropriate, be completely filled out, and dated.