Every finding on record at Adoration Home Health Care Maryland LLC

A standard Medicare recertification home health agency was conducted on December 7, 8, 9, 13, and 14, 2021. The survey included reviews of clinical records, selected agency policy and procedures, admission packet including the patient’s bill of rights, complaint and incident logs, on-call policy, schedules and logs, personnel files, organizational chart, quality assessment performance improvement (QAPI), emergency preparedness plan, CLIA waiver and interviews with the agency’s administrative staff. A total of seventeen randomly selected clinical records were reviewed. The services included were: Skilled nursing – Ten Physical Therapy – Twelve Occupational Therapy – Four Home Health Aide – Three Speech Therapy – One All findings were based on data present on the date of the review. A keycode was provided to the agency’s Administrator. The agency’s administrative staff was kept informed of the survey findings as the survey progressed. The agency staff was given the opportunity to present information relative to the findings during the survey.

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 a review of clinical records, the agency’s administration failed to ensure that an assessment of the patient by nursing or rehabilitation therapy occurred within 48 hours of referral for 7 out of 17 patients reviewed. The agency not performing assessments timely placed the patients at risk for delays in care and adverse health care outcomes. Patients: #1, #3, #6, #9, #10, #12 and #14 The findings include: On 12/13/2021, a review of Patient #1’s referral intake note revealed the referral date 6/2/2021. The patient start of care (SOC) was 6/7/2021. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request. On 12/14/2021, a review of Patient #3’s referral intake note revealed the referral date of 7/15/2021. The patient's SOC was 7/21/2021. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request.On 12/9/2021, a review of Patient #6’s referral intake note revealed the referral date of 1/21/2021. The patient's SOC was 1/27/2021. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request. On 12/13/2021, a review of Patient #9’s referral intake note revealed the referral date of 9/1/2021. The SOC was 9/14/2021. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request. On 12/9/2021, a review of Patient #10’s referral intake note revealed the referral date of 11/28/2020. The SOC was 12/2/2020. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request. On 12/13/2021, a review of Patient #12’s referral intake note revealed the referral date of 10/25/2021. The SOC was 10/29/2021. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request.On 12/13/2021, a review of Patient #14’s referral intake note revealed the referral date of 2/23/2021. The SOC was 3/4/2021. There was no documentary evidence to support that a physician ordered a change to the SOC or that the patient or family made a request.On 12/13/2021, a review of the agency’s policy entitled “Referral/Intake Process” revealed, in part, “All steps must be completed in a timely manner to support the admission of the to care within 48 hours”.Initial assessments must occur within 48 hours of a referral, a patient’s return home, or the physician ordered start of care date. An agency shall not change the SOC to accommodate the agency’s convenience.

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 clinical record review, the skilled professional (SP) failed to notify the patient's physician of an abnormal assessment finding. The SP not advising the physician of such findings can result in delays in care and adverse patient outcomes. Patient #8 Findings include: Physicians set parameters (guidelines) for vital signs (blood pressure, heart rate, and oxygen level) to measure how patients' vital organs are functioning. The SP has the responsibility to notify the physician of an abnormal assessment finding. On 12/9/2021, a clinical record review revealed that on the 9/30/2021 nurse visit, Patient #8's blood pressure (BP) reading was 180/90. The nurse noted during the visit that the patient vital signs were WNL (within normal limits). The patient's BP was above the physician-ordered systolic parameter (Systolic170). There was no documentary evidence that the abnormal reading was reported to the patient's physician as ordered.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on a review of the agency's Quality Assessment Performance Improvement (QAPI) and interview with the agency's administrative staff, the agency's governing body failed to develop an appropriate performance improvement project. This placed the agency's patient population at risk of poor patient outcomes and poor services from the agency. Findings included: During the survey, the agency's administrative staff initially provided incomplete QAPI information for review. The QAPI start date was December 15, 2020, with a target completion of June 15, 2021. This surveyor requested to see the data and the analysis of the data. There was no documentary evidence that this process had occurred. The QAPI goals should be specific, measurable, actionable, and have a timeline for completion. There was no data or analysis performed by the agency's administrative staff.During an interview with the agency's administrative staff, this surveyor requested to see all QAPIs' developed by the agency along with the data collected for them following the 2017 re-certification survey. The administrative staff confirmed that no QAPIs' were developed and/or completed. This surveyor had discussions with the agency's quality staff, and he/she understood how the QAPI is to be data-driven and address problem areas that impact patient outcomes, quality of care, safety, and services provided by the agency.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on this surveyor's request to review the agency's QAPI and interview with the agency's administrative staff, the agency's governing body failed to ensure the appropriate development and implementation of a QAPI. This placed the agency's patient population at risk of poor patient outcomes and poor services from the agency. Findings included: During the survey, the agency's administrative staff initially provided incomplete QAPI information for review. The QAPI start date was December 15, 2020, with a target completion of June 15, 2021. This surveyor requested to see the data and the analysis of the data. There was no documentary evidence that this process had occurred. The QAPI goals should be specific, measurable, actionable, and have a timeline for completion. There was no data or analysis performed by the agency's administrative staff. 2. During an interview with the agency's administrative staff, this surveyor requested to see all QAPIs' developed by the agency along with the data collected for them following the 2017 re-certification survey. The administrative staff confirmed that no QAPIs' was being developed and/or completed. This surveyor had discussions with the agency's quality staff, and he/she understood how the QAPI is to be data-driven and address problem areas that impact patient outcomes, quality of care, safety, and services provided by the agency. The governing body’s responsibility is to ensure that QAPI is a priority within the organization. Effective QAPI programs can lead to the development of necessary policies and procedures, identify quality and safety problems, and lead to opportunities for improvement.