Every finding on record at Ace Home Health Services Corp

During the recertification survey conducted on 07/12/2022 to 07/14/2022 at ACE Home Health Services Corp., a Home Health Agency, Emergency Preparedness was reviewed. ACE Home Health Services Corp. is in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 07/12/2022 to 07/14/2022 at ACE Home Health Services Corp. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate it had obtained the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 1 out of 10 Sampled Patients (SP). SP#9 Findings include: Closed clinical record review of SP#9 revealed a start of care date 03/31/2022 with the Client Service Agreement signed and dated 03/31/22. Further review under “Relationship of Authorized Representative” reads “ALF (Assisted Living Facility) Staff”. The Director of Nursing on 07/13/22 at 11:06 AM stated that she obtained verbal consent from the patient’s daughter to commence the service. The patient’s daughter signed the form “Authority to Sign on Behalf of Patient” and the agency believed the ALF Administrator could sign the consent for the service. The DON confirmed the signature on the service agreement form is the ALF Administrator's signature and not the patient's legal representative (the patient's daughter).

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed discharge summary for 2 out of 10 Sampled Patients (SP). SP#9, SP#10 Findings include: Closed record reviews of the SP#9 and SP#10 were conducted on 07/12/22 to 07/13/22. Review of the SP#9 closed clinical record contained a discharge summary from agency with discharge date 05/03/22; and review of the SP#10 closed clinical record contained a discharge summary from agency with discharge date 07/01/22. The “Discharge Summary” form for SP#9 and SP#10 omitted information of the following areas: does not list reason for admission to home health; omits the type of services provided and frequency of services; omits any Lab data; does not list the summary of care/outcomes in meeting the goals in the Plan of Care; omits discharge condition notation, and post-discharge instructions. Interview conducted with the Director of Nursing on 07/14/22 at 3:10 PM. The Director of Nursing reviewed the discharge summary for SP#9 and SP#10 and acknowledged that summaries were incomplete, missing the required notations as previously mentioned.