Every finding on record at Adaptive Nursing and Healthcare Services, LLC

This was a Federal recertification and State re-licensure survey of a home health agency. The survey was partially extended on 1/25/22 at 1:30 PM. Dates of Survey: January 18, 19, 20, 21, 24, and 25 of 2022. Facility ID: 14340 Unduplicated Admissions for Previous 12 Months: 102 Active Census: 96 These deficiencies reflect State findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR Completed 2/23/2022 A4

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Registered Nurse (RN)[CL1] failed to conduct a comprehensive assessment of a patient’s lung sounds for 1 of 1 home visit observations of a skilled nursing visit (Patient #3) and failed to conduct a comprehensive assessment of a patient’s wounds for 1 of 1 active records reviewed of patients with an active wound (Patient #5). Findings include: 1. An agency policy titled “Nursing Documentation of Client Assessment,” last revised 1/4/22, indicated but was not limited to “… Procedure: 1. A thorough, well organized, comprehensive and accurate assessment, consistent with the client’s immediate needs will be completed/documented for all clients … 4. The nursing comprehensive assessment will include,but is not limited to: … d. Respiratory status and Oxygen safety … i. Integumentary [skin] status. j. Pressure ulcer risk assessment, prevention measures and effective healing principles ….” 2. An agency job description titled “Registered Nurse Case Manager” and revised 4/8/21, indicated but was not limited to “… Essential Functions/Areas of Accountability … 2. Performs initial and ongoing client assessments based on Agency policy and standards of practice to ensure effective and appropriate home care services ….” 3. Constantine, Salmon, & Maryniak (January 16, 2012). "Overview of Nursing Health Assessment." Retrieved 1/19/21 from RN.com. " ... Pulmonary Assessment ... Auscultate the anterior and posterior chest: Have patient breath slightly deeper than normal through their mouth. Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should auscultate between every rib ... Identify any adventitious breath sounds ..." 4. Nagle, Waheed, Wilbraham. (2021). “Wound Assessment.” Retrieved 1/31/2022 from www.ncbi.nlm.nih.gov. “… A wound in damage or disruption of the skin, and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment … Nursing, Allied Health, and Interprofessional Team Interventions. Generally, ongoing nursing and clinician assessments and monitoring of wounds are similar: … Determine the state of the wound. Evaluate and measure the depth, length, and width of the wound. Measure the amount of undermining and tunneling. Evaluate the wound bed. Assess for [presence], type, and amount of exudate … [Assess] surrounding skin tissue … Evaluate for signs and symptoms of [infection] … Document findings … Nursing, Allied Health, and Interprofessional Team Monitoring. Wound checks are typically once per shift ….” 5. A home visit observation was conducted on 1/18/22 at 3:40 PM with Patient #3 (start of care 4/2/2020) and RN #1. During the visit, RN #1 auscultated the patient’s lung sounds within two anterior (chest) quadrants and four posterior (back) quadrants. The RN failed to perform an assessment of all lung lobes. 6. The clinical record of Patient #5 was reviewed on 1/24/22 and indicated a start of care date of 2/25/2021, with patient diagnoses including but not limited to multiple sclerosis, decubitus ulcer (wound caused from prolonged pressure on a specific location of the body) of the right hip, and decubitus ulcer of the coccyx (triangular shaped portion of bone located at the end of the spine). The record included a plan of care for the certification period 12/22/21 – 2/19/22 which indicated the patient received skilled nursing services from Home Health Agency #1 twice a week for “wound care.” The record also included a resumption of care assessment completed on 1/7/22 by Administrator/Clinical Manager. The assessment indicated but was not limited to “… Integumentary/Wound Care … Wound #1. Location: Sacral region [portion of the spine which includes the last 4 vertebra and coccyx]. Type: pressure wound. Stage: NA [not applicable] … Wound #2. Location: Right hip. Type: pressure ulcer. Stage: NA … Comments: … Unable to assess wound at today’s visit due to new dressing just recently being applied. Client continues to receive wound care from [Home Health Agency #1] twice weekly ….” The assessment failed to evidence the RN assessed and documented the patient’s wounds for type of dressing, frequency of dressing changes, pressure wound staging, measurements, and presence or absence of drainage, odor, or signs of infection. An interview of Patient #5 was conducted on 1/19/22 at 11:40 AM. During the interview, Patient #5 confirmed her wounds were changed daily by either her family member or Home Health Agency #1. Patient #5 also confirmed the registered nurses from Adaptive Nursing and Healthcare Services did not assess the patient’s wounds when they visited. 7. An interview was conducted on 1/20/22 at 11:30 am with the Administrator/Clinical Manager and Alternate Administrator. During the interview, the Administrator/Clinical Manager confirmed the registered nurse should assess the patient’s lung sounds by “[using] a stethoscope to listen in all front quadrants and back quadrants and bilateral [both] sides.” 8. An interview was conducted on 1/25/22 at 1:14 PM with the Administrator/Clinical Manager and Alternate Administrator. During the interview, the Administrator/Clinical Manager confirmed the RN should assess a patient’s wound(s) during an in-home visit “as long as a dressing isn’t there” that was placed by another skilled nursing agency. The Administrator/Clinical Manager also confirmed if a patient received wound care from another agency, the patient’s nurse case manager performed care coordination with the skilled nursing agency by confirming the agency was still performing care and requesting a plan of care from the other agency.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence detailed and specific Home Health Aide (HHA) care plans for 4 of 6 active records reviewed (Patients #1, 3, 4, 5). Findings include: 1. An agency policy titled "Home Health Aide Care Service Plan,” last revised 1/4/2022, indicated but was not limited to “… A complete and appropriate Care Service Plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse … The Home Health Aide cannot be responsible for performing any procedure that is not assigned to him/her in writing by the Registered Nurse ....” 2. The clinical record of Patient #1 was reviewed on 1/24/21 and indicated a start of care date 3/9/21, and patient diagnoses included but not limited to chronic pain syndrome, chronic obstructive pulmonary disease (COPD), lupus, and epilepsy. The record included a plan of care for the certification period 1/3/22 - 3/3/22, which indicated orders for home health aide services 8 hours per day, 7 days per week. The record also included Daily Visit Sheets for HHA visits completed with Patient #1. Daily Visit Sheets completed on 1/8/22, 1/10/22, 1/17/22, and 1/19/22 indicated Patient #1 received HHA services in two separate shifts. The record included a “Plan of Care Service Plan” for HHAs, reviewed and signed by the Alternate Clinical Manager on 1/3/22. The aide care plan failed to evidence clear and detailed directions on which tasks were to be performed when the patient's HHA services were divided into two different shifts. 3. The clinical record of Patient #3 was reviewed on 1/24/22 and indicated a start of care 11/3/2020, with patient diagnoses including but not limited to Duchenne Muscular Dystrophy, cardiac arrhythmia, and high blood pressure. The record included a plan of care for the certification period 12/25/21 - 2/25/22, which indicated orders for home health aide services 4 hours per day, 5 days per week. The plan of care also indicated the “HHA [was] to assist with all ADLs such as bathing (bed bath), hair care, dressing, meal prep, positioning, laundry, toileting, light housekeeping, and transfers.” The record included a “Plan of Care Service Plan” for HHAs, reviewed and signed by the Alternate Clinical Manager on 12/26/21. The aide care plan indicated tasks to be performed included but were not limited to “... Bed Bath. Frequency: 2 x Week. Plan Notes: Full bed bath … Partial Bath. Frequency: 3 x Week. Plan Notes: Partial bed bath ….” The care plan failed to evidence clear and precise directions on when the aide was to perform a full vs partial bed bath. 4. The clinical record of Patient #4 was reviewed on 1/19/22 and indicated a start of care 12/22/21, with patient diagnoses including but not limited to Hemiplegia (paralysis of one side of the body) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), muscle stiffness, depression, insomnia, overactive bladder, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and dysphagia (difficulty swallowing). The record included a plan of care for the certification period 12/22/2021-2/19/2022, which indicated orders for home health aide services 8 hours per day, 5 days per week. The plan of care also indicated the aide was to “monitor for fall risks such as stumbling, shuffling or unsteady gait, weakness, or dizziness. Keep pathways clear of clutter and obstacles, encourage use of electric wheelchair/walker.” The record included a “Plan of Care Service Plan” for HHAs, reviewed and signed by the Clinical Manager on 12/22/2021. The aide care plan failed to evidence the HHA was tasked with monitoring for patient falls risks, keep pathways clear, and encourage the patient to use their electric wheelchair or walker.. 5. The clinical record of Patient #5 was reviewed on 1/21/22 and indicated a start of care 2/25/21, with patient diagnoses including but not limited to multiple sclerosis, neurogenic bladder, anxiety, depression, chronic pain, gastroesophageal reflux disease (GERD), and pressure ulcer wounds to the right hip and coccyx (tailbone) area. Patient was also hospitalized 1/3/22-1/6/22 for acute respiratory failure. The record included a plan of care for the certification period 12/22/21-2/9/22, which indicated orders for home health care services 5 hours per day, 5 days per week. The plan of care also indicated the patient had a suprapubic cathether (type of urinary catheter placed into a surgically created stoma in the lower abdomen), and the aide was to "report to RN [nurse] of any dislodgement, decreased urine output, abnormal smell, discoloration, or any pain/burning [with urination].” The record included a “Plan of Care Service Plan” for HHAs, reviewed and signed by the Clinical Manager on 1/7/2022. The aide care plan failed to direct the HHA to report to the RN problems with the suprapubic catheter or abnormal urinary symptoms as ordered in the plan of care. 6. An interview was conducted on 1/25/2022 at 1:15 PM with the Administrator/Clinical Manager and Alternate Administrator. During the interview, the Administrator/Clinical Manager confirmed when patients had more than one aide shift but only one aide care plan, the care plan should specify which task was assigned for each shift. The Administrator/Clinical Manager confirmed for patients who had both a full and partial bed bath tasks within the care plan, it was up to “client preference” whether a full or partial bath was to be performed each day, and this direction should be clearly indicated within the aide care plan. The Administrator/Clinical Manager also confirmed precautions or specific symptoms for the aide to report which were ordered within the plan of care should be included on the aide care plan.