Every finding on record at Acts Home Health Care, Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 observations, interviews, and record reviews, the agency failed to ensure agency nursing and therapy staff reviewed correlation of identified patient home medications and current physician ordered medications for 3 (Patient #1, Patient #2, Patient #3) of 4 (Patient #1, Patient #2, Patient #3, Patient #4 ) sampled patients observed during home visits. Findings: Review of the agency’s Medication Reconciliation policy and procedure revealed, in part, The agency will perform a medication reconciliation during each patient visit to prevent medication errors and adverse drug interactions. Further review revealed Medication Reconciliation was defined as the process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency, and route, and comparing that list against the physician’s orders at transitions of care. Still further review revealed the policy applied to all healthcare professionals involved in patient care within the agency, including nurses and therapists. In an interview on 03/31/2025 at 10:40AM, S1Administrator/Registered Nurse (RN) indicated nurses and therapist were responsible for the reconciliation of patient medications on each home visit. When asked, if reconciliation included the nurse or therapist checking the actual patient’s medication bottles and containers in the home to the agency’s current list of the patient’s physician ordered medications, S1Administrator/RN answered “yes.” Observation on 03/31/2025 at 1:30PM of Patient #1’s home visit revealed S2Licensed Practical Nurse (LPN) did not reconcile Patient #1’s medications during the visit. In an interview on 03/31/2025 at 1:31PM, S2LPN indicated she reconciled Patient #1’s medications every Wednesday, but not every visit which was three times per week. Observation on 03/31/2025 at 2:25PM of Patient #2’s home visit revealed S3Licensed Practical Nurse (LPN) did not reconcile Patient #2’s medications during the visit. In an interview on 03/31/2025 at 2:25PM, S3LPN indicated she reconciled Patient #2’s medications last week, but did not reconcile Patient #2’s medications on every visit. Observation on 04/01/2025 at 12:20PM of Patient #3’s home visit revealed S4Occupational Therapist (OT) did not reconcile Patient #3’s medications during the visit. In an interview on 04/01/2025 at 12:20PM, S4OT indicated he had not reconciled Patient #3’s medications on any visit, because the nurses reconciled medications on their visits. Record review of Patient #4’s Home Health Certification and Plan of Care for the certification period of 03/13/2025 to 05/11/2025 revealed Patient #4 had orders for only one nurse visit at the beginning of the certification period. In an interview on 04/02/2025 at 4:15PM, S1Administrator/RN indicated all nurses and therapists are required to reconcile medications on every visit.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Registered Nurse(RN) assessed and measured pressure ulcers and wounds weekly for 3 (Patient #1, Patient #5, Patient #6) of 5 (Patient #1, Patient #5, Patient #6, Patient #7, Patient #10) sampled patient’s records reviewed for pressure ulcers and wounds. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; and evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #1 Review of Patient #1's Home Health Certification and Plan of Care for the certification period of 02/13/2025 to 04/13/2025 revealed Patient #1 was to receive skilled nursing services once for 1 week and then 3 times per week for 8 weeks. Further review revealed the skilled nurse was to provide dressing changes and wound/pressure ulcer care. Review of Patient #1's Skilled Nursing Visit Note Reports revealed S2Licensed Practical Nurse (LPN) documented wounds every visit from 02/12/2025 to 03/26/2025, with the same measurements. Further review of Patient #1's Skilled Nursing Visit Note Reports revealed no documentation of any RN visits with wound/pressure ulcer documentation, and the agency did not present any documented evidence of any RN visits with wound/pressure ulcer documentation. Review of Patient #1's RN Recertification Outcome and Assessment Information Set (Oasis) Report dated 02/12/2024 revealed no documentation of wounds/pressure ulcers, and the agency did not present any documented evidence to wounds/pressure ulcers. Patient #5 Review of Patient #5's Home Health Certification and Plan of Care for the certification period of 02/24/2025 to 04/24/2025 revealed Patient #5 was to receive skilled nursing services 3 times per week for 9 weeks. Further review revealed the skilled nurse was to provide dressing changes. Review of Patient #5's Skilled Nursing Visit Note Reports revealed S2LPN documented wounds every visit from 02/24/2025 to 03/19/2025, with the same measurements. Further review of Patient #5's Skilled Nursing Visit Note Reports revealed no documented evidence and the agency did not present any documented evidence of any RN visits with wound/pressure ulcer documentation. Patient #6 Review of Patient #6's Home Health Certification and Plan of Care for the certification periods of 01/15/2025 to 03/15/2025 and 03/16/2025 to 05/14/2025 revealed Patient #6 was to receive skilled nursing services 2 times per week for 1 week; then 3 times per week for 8 weeks; then three times per week for an additional 8 weeks; and 2 times per week for 1 week. Further review revealed the skilled nurse was to provide dressing changes and wound/pressure ulcer care. Review of Patient #6's Skilled Nursing Visit Note Reports revealed S2LPN measured wounds every visit from 01/15/2025 to 03/28/2025. Further review of Patient #6's Skilled Nursing Visit Note Reports revealed no documented evidence and the agency did not present any documented evidence of any RN visits with wound/pressure ulcer documentation. Review of Patient #6's RN Recertification Oasis Report for Recertification period 01/15/2025 to 03/15/2025 revealed no documentation of wounds/pressure ulcer measurements, and the agency did not present any documented evidence of RN wounds/pressure ulcer measurements for this period. In an interview on 04/02/2025 at 4:30PM, S1Administrator/RN indicated Patient #1, Patient #5, and Patient #6’s wounds were not measured by an RN weekly as required.

The entity is in compliance with the federal emergency preparedness requirements.

Recertificaiton Survey

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure Patient #5 received skilled nursing services 8 hours daily throughout the 60 day certification period for 1 of 1 sampled patient (Patient #5) reviewed for extended home health services in a total sample of 13. Findings: Review of Patient #5’s CPOC (Comprehensive Plan of Care) for certification period of 05/15/2022 to 05/14/2023 revealed Patient #5 was to receive skilled nursing services 8 hours a day, 7 days a week. Review of Patient #5’s Home Health Certification and Plan of Care for certification period of 06/18/2022 to 08/16/2022 revealed Patient #5 was to receive skilled nursing care 8 hours a day for 60 days. Review of Patient #5’s Nursing Notes and Time Sheets revealed Patient #5 received the following amount of services, in part: 06/19/2022 no services were provided; 06/20/2022 7.5 hours of services provided; 06/21/2022 7.5 hours of services provided; 06/22/2022 7 hours of services provided; 06/23/2022 7.5 hours of services provided; 06/26/2022 7.25 hours of services provided; 06/27/2022 6.25 hours of services provided; 06/28/2022 5.5 hours of services provided; 06/29/2022 7 hours of services provided; 06/30/2022 7.25 hours of services provided; 07/01/2022 7.5 hours of services provided; 07/03/2022 no hours of services provided; 07/05/2022 7 hours of services provided; 07/07/2022 7 hours of services provided; 07/10/2022 7.25 hours of services provided; 07/11/2022 7.5 hours of services provided; 07/12/2022 7.5 hours of services provided; 07/13/2022 7 hours of services provided; 07/15/2022 7 hours of services provided; and, 07/17/2022 no hours of services provided. In an interview on 07/26/2022 at 1:30pm, Patient #5’s caregiver stated the skilled nurse often comes to work late, and if the nurse cannot come in to work the agency does not have a backup staff. Patient #5’s caregiver stated we were willing to have other nursing staff when the scheduled nurse cannot make it in. In an interview on 07/28/2022 at 2:00pm, S1Administrator stated the agency had an issue with Patient #5’s skilled nurse starting work on time. S1Administrator further stated the agency had a problem staffing extended home health patients due to the pay/reimbursement, and therefore the agency was not always able to provide 8 hours of services daily.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the agency’s QAPI (Quality Assessment and Performance Improvement) program included review of potentially avoidable events. Findings: Review of the agency’s Potentially Avoidable Event Patient Listing Report revealed potentially avoidable events were identified in the following areas: development of urinary tract infections (bladder infections); increase in the number of pressure ulcers; substantial decline in 3 or more activities of daily living; and discharged to the community with an unhealed stage 2 pressure ulcer. Review of the agency’s QAPI Program for 2021 and 2022 revealed no documented evidence of the provider having included adverse patient events as part of the agency’s QAPI. In an interview on 07/28/2022 at 1:22pm, S1Administrator stated the agency was not incorporating the potentially avoidable events as part of the agency’s QAPI program. S1Administrator further stated the agency was not even printing out the reports of the adverse patient events.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the skilled nurse obtained weekly wound care measurements to monitoring for wound healing status for 1 of 6 sampled patients (Patient #13) reviewed for wound care assessment in a total sample of 13. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes, in part: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Review of Patient #13’s Home Health Certification and Plan of Care for certification period of 01/14/2022 to 03/14/2022 revealed a stage 4 pressure ulcer (wound with bone exposed) to the sacral area. Review of Patient #13’s Record revealed no documented evidence and the agency presented no documented evidence of wound care measurements having been obtained on Patient #13’s wounds at any time during the certification period. In an interview on 07/28/2022 at 2:14pm, S1Administrator stated wound care measurements were not obtained, but wound care measurements should have been obtained weekly.