Every finding on record at Accucare Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/19/24. Standard level deficiencies cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based of review of Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Plan was established based on a risk assessment using an all hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 04/17/24 at 11:45 AM. The plan lacked documentation that a facility-based and/or community based risk assessment was completed for 2021, 2022 and 2023. 2. During an interview with the Director of Nursing on 04/17/24 at 3:30 PM, the Director of Nursing confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 04/19/24. Standard level deficiencies cited. Abbreviations: mcg = microgram/s mg = milligram/s POC = Plan of Care Pt. = Patient Pts. = Patients SN = Skilled Nurse SOC= Start of Care

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on the review of the admission packet, home visit observations, and staff interview, it was determined in 3 of 7 (Pts.#1, 2 and 3) clinical records reviewed, the Agency failed to provide patients the Agency's transfer and discharge policies. Findings include: 1. The Admission packet was reviewed on 04/16/24 and lacked the Agency’s transfer and discharge policies. 2. It was observed during the home visits, conducted on 04/16/24 and 04/17/24, the home folders lacked the transfer and discharge policies for: Pt #1 SOC:11/02/23. Pt #2 SOC: 03/07/24. Pt #3 SOC: 04/11/24. 3. The findings were confirmed, during the interviews with the Administrator and Director of Nursing, on 04/18/24 between 12:00 PM and 12:30 PM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 4 of 7 (Pts. # 2, 1, 3 and 6) clinical records reviewed the Agency failed to provide the care as ordered by the physician. 2. Pt. #1 was admitted to Home Health Services on 11/02/23 with Diagnosis of Hemiplegia following other cerebrovascular disease affecting left nondominant side. The clinical record was reviewed on 04/16/24 and 04/17/24. The POC effective 03/01/24 included the following medications: “….Fluorouracil cream….Amlodipine….Atorvastatin....Vitamin B12 500 mcg….Vitamin D3…. Lansoprazole….Aspirin 325 mg…. Stool Softener….”. A home visit was conducted with the Director of Nursing/Registered Nurse on 04/17/24 at 8:00 AM and the following medications were observed in Pt. #1’s home: 1 bottle of Vitamin C 1000 mg, 1 bottle Aspirin 81 mg, 1 bottle Vitamin B12 1000 mcg and 1 bottle of Dry Eye relief eye drops. During interview with Pt. #1’s caregiver on 04/17/24 at 8:30 AM, it was stated that Pt. #1 uses the medications listed above. The medications observed were not listed as ordered by the physician. 3. Pt. # 3 was admitted to Home Health Services on 04/11/24 with Diagnosis of Hypothyroidism. The clinical record was reviewed on 04/16/24. The POC effective 04/11/24 included the following medications: “….Bupropion….Brexpriazole….Clindamycin….Cyclobenzaprine Hydrochloride….Diazepam….Voltaren….Duloxetine….Frova….Lamotrigine….Levothyroxine….”. A home visit was conducted with the Director of Nursing/Registered Nurse on 04/17/24 at 1:00 PM and the following medications were observed in Pt.# 3’s home: 1 bottle of Propanolol….1 bottle of Ondansetron… 1 bottle of Aspirin….1 bottle of Vitamin C….1 bottle of Topiramate….1 bottle of Vitamin D3….1 bottle of Potassium Citrate….1 bottle of Magnesium….1 bottle of Multivitamins….1 bottle of Lecithin…1 bottle of Morphine Sulfate….and 1 Naloxone nasal spray. During interview with Pt. #3 on 04/17/24 at 1:30 PM, it was stated that he has been taking these medications. The medications observed were not listed as ordered by the physician. 4. Pt. #6 was admitted to Home Health Services on 02/27/24 with Diagnosis of Pressure ulcer sacral region stage 2, Atherosclerosis Native Arteries of right leg with Ulcer and Pressure ulcer of the site, stage 1. The clinical record was reviewed on 04/16/24 and 04/17/24. The SOC assessment dated 2/27/24, indicated stage 2 sacrum pressure ulcer, right foot arterial ulcer and right knee stage 1 pressure ulcer. The POC effective 02/27/24, indicated: “….Medications….Silver Sulfadiazine ext cream tube 1 2 x a day topical….orders for discipline and treatment….SN to perform pressure ulcer care to sacrum. Cleanse/irrigate wound with saline solution, apply alginate/duoderm, cover and secure with bandage….” The SN notes dated 03/01/24, 03/05/24, 03/08/24 and 03/13/24, contained documentation: “Integumentary…. Comment….2 inches diameter arterial ulcer ball right foot; skin warm and moist; maxsorb alginate/duoderm dressing to sacrum; Optifoam gentle silicone bordered foam; Puracol plus fenestrated wound dressing around edges; gauze around edges to avoid leakage of secretions. Right knee stage 1 ulcer treat with Silver Sulfadiazine…” The SN was not following wound care interventions as ordered by the physician. 5. During interviews with the Administrator and Director of Nursing on 04/17/24 from 10:00 AM to 11:00 AM and with Director of Nursing on 04/17/24 at 2:30 PM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. #2 was admitted to Home Health Services on 03/07/24 with the Diagnosis of: Alzheimer’s Disease Unspecified. The clinical record was reviewed on 04/16/24. The POC dated 03/07/24, included SN orders to assess the patient 1 time a week for 9 weeks. The SN failed to assess the patient during the week of 03/17/24 (week #3).

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 the onsite observations and staff interview, it was determined the Agency failed to ensure the Administrator maintained responsibility for all day-to-day operations. Findings include: 1. Surveyor arrived at Agency on 04/16/24 at 9:00 AM. It was observed no one was at the Agency. Several calls were made to the Agency between 9:00 AM and 9:40 AM, with no answer and no ability to leave a message. Agency staff arrived at 9:40 AM. The Administrator arrived after 11:00 AM. The Administrator failed to maintain the Agency's documented operating hours of 9:00 AM through 5:00 PM Monday to Friday. 2. The findings were confirmed with the Administrator and Director of Nursing, on on 04/18/24 between 12:00 PM and 12:30 PM.

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 5 of 7 (Pts. #3, 5, 2, 4 and 7) records reviewed, the clinical records were not completed as required. 3.Pt. #2 was admitted to Home Health Services on 03/07/24 with the Diagnosis of: Alzheimer’s Disease Unspecified. The clinical record was reviewed on 04/16/24. The clinical record included an incomplete “Service Agreement, Consent and Authorization” form. The form lacked the information for the advance directives. 4. Pt. #4 was admitted to Home Health Services on 03/07/24 with the Diagnosis of: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 04/16/24. The clinical record included an incomplete “Service Agreement, Consent and Authorization” form. The form lacked the information for the advance directives. 5. Pt. #7 was admitted to Home Health Services on 06/08/23 with the Diagnosis of: Alzheimer’s Disease Unspecified. The clinical record was reviewed on 04/16/24. The clinical record included an incomplete “Service Agreement, Consent and Authorization” form. The form lacked the information for the advance directives and lacked the date of the patient signature. The clinical record also lacked the specific information regarding the summary of patient care. 6. The Agency’s Policy titled “Entries into the Clinical Record” was reviewed on 04/17/24 at 1:00 PM. The policy included “…PROCEDURE 1. A clinical record…will include at a minimum: A. Patient consent, authorization, and election forms, as applicable …E. Dates, times and types of interventions, assessments, and coordination of care… 3. Entries into the clinical record will be clear, concise and specific statements of fact…” 7.The findings were confirmed with the Administrator and Director of Nursing, on 04/17/24 between 10:00 AM and 2:30 PM. Findings include: 1. Pt. # 3 was admitted to Home Health Services on 04/11/24 with Diagnosis of Hypothyroidism. The clinical record was reviewed on 04/16/24. The Service Agreement, Consent and Authorization form dated 04/11/24 at the start of care and signed by Pt. #3 and admitting Nurse, lacked information on Advanced directives. 2. Pt. #5 was admitted to Home Health Services on 02/23/24 with Diagnosis of Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 04/16/24. The Service Agreement, Consent and Authorization form dated 02/23/24 at the start of care and signed by Pt. #5 and admitting Nurse, lacked information on Advanced directives.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 4/30/2021. The facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: SOC= Start of Care POC= Plan of Care PsOC= Plans of Care AM= Morning PM= Afternoon/Evening PT= Physical Therapy/Therapist RBS= Random Blood Sugar SN= Skilled Nurse DON= Director of Nursing mg/dl= milligrams per deciliter #= Number

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: Findings Include: A. Based on clinical records reviewed and staff interviews, it was determined the Agency failed to ensure the Plans of Care were implemented as ordered. This was found in 3 of 7 (Pts. #7, 4 and 6) clinical records reviewed. 1. Pt. #7 SOC 11/20/2020 Primary Diagnosis: Spondylosis without myelopathy or radiculopathy, lumbar region. The clinical record was reviewed on 4/28/2021 at 11:00 AM. The POC for certification period 1/19/2021-3/19/2021 included, " ...Physical Therapy to assess functional status ... PT to assess rehabilitation potential ... PT to establish a home exercise program." The clinical record lacked evidence of a PT evaluation. During an interview with the Quality Analyst Nurse on 4/29/2021 at 10:30 AM, it was confirmed that PT was not provided for the patient as ordered in the POC. 2. Pt. # 4 SOC 1/11/2021 Diagnosis: Pressure Ulcer of Right Lower Back Stage 2. The clinical record was reviewed on 4/29/2021 at 1:00 PM the clinical record contained a POC for certification period 1/11/2021 to 3/11/2021 that contained intervention orders for wound care orders as " Cleanse / irrigate wound with wound cleanser, apply neosporin ointment , cover and secure with hypoallergenic tapes". The SN clinical notes 1/30/2021 and 2/3/2021 contain wound care as "cleaned aseptically and dry. neosporin ointment applied and medihoney." During an interview with the Assistant Administrator and Quality Analyst Nurse it was confirmed the SN was not following interventions as ordered in the POC. 3. Pt. # 6 SOC 1/21/2021 Diagnoses: Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified open wound, right foot sequela. The clinical record was reviewed on 4/28/2021 at 11:00 AM. The record contained a POC for certification period 1/21/2021 to 3/21/2021 that contained intervention wound orders care orders as "apply santyl and medihoney, cover and secure with sterile gauze and tape". The weekly SN notes beginning 1/27/2021 contain wound care as "keep clean with sterile dressing and neosporin ointment". During an interview with the Assistant Administrator and Assisting DON on 4/29/2021 at 11:00 AM it was confirmed SN not following intervention as ordered in the POC. 4. During interviews with the Alternate Administrator, Alternate DON and Quality Analyst Nurse on 4/29/2021 between 10:00 AM and 11:00 AM findings of Agency staff not providing services and treatments established on the PsOC were confirmed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: A. Based on clinical records review and staff interviews it was determined that the Agency failed to ensure that clinical notes / assessments were complete and accurate. This was found in 2 of 7 clinical records reviewed ( Pt's #6 and #3) Findings include: 1. Pt. # 6 SOC 1/21/2021 Diagnoses: Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified open wound, right foot sequela. The clinical record was reviewed on 4/28/2021 at 11:00 AM. The record contained a POC for certification period 1/21/2021 to 3/21/2021 that describes wound care and description of pressure ulcers to Left Heel and Right Foot. The clinical record contains SN visit notes beginning on 1/27/2021 with wound description of Sacral wound. During an interview with Alternate Administrator on 4/29/2021 at 11:00 AM it was stated that the documentation should reflect left and right foot wound and confirmed that the documentation is inaccurate. 2. Pt. #3 SOC 3/26/2021 Primary Diagnosis: Polyosteoarthritis. The clinical record was reviewed on 4/27/2021 at 12:15 PM. SN Visit note dated 4/21/2021 included, "Endocrine/Hematologic ... comment ... RBS= 168mg/dl." The visit note also included, "Visit Narrative ... Random blood sugar 155 mg/dl." SN Visit note dated 4/27/2021 included, "Endocrine/Hematologic ... comment ... RBS= 168mg/dl." The visit note also included, "Visit Narrative ... Random blood sugar 155 mg/dl." During an interview with the Quality Analyst Nurse, the Alternate Administrator and Alternate DON at 10:30 AM on 4/29/2021 it was confirmed the RBS was inaccurately documented. 3. During an interview with the Alternate Administrator, Alternate DON and Quality Analyst Nurse on 4/29/2021 between 10:30 AM and 11:00 AM the above findings were confirmed.