Every finding on record at Adoration Home Health Care Maryland LLC

A recertification survey of SpiriTrust Lutheran Home Care & Hospice for the Condition for Coverage of Home Health Agencies was conducted May 18 and 20, 2021. After the review of the agency's emergency preparedness program and plan, the agency was found to be in compliance with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

A standard survey was conducted at SpiriTrust Lutheran Home Care & Hospice located in Westminster, Maryland on May 18 and 20, 2021. The survey included the review of patient medical records, personnel files, on-call logs, and complaint/incident logs. Outcome and Assessment Information Set data, patient rights information, and selected policies were also reviewed. No home visits were conducted, however, a total of fifteen clinical records were reviewed during the survey. The represented scope of services as follows: Skilled Nursing Services-Eleven Physical Therapy Services- Seven Occupational Therapy Services-four Medical Social Worker- One Speech Language Pathology Services- One Home Health Aide Services -Four A patient key-code was provided to the agency administrator during the exit conference. The administrator also signed and received a copy of the plan of correction verification form during the exit conference.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on the review of patient records and interview with the agency staff, the agency's skilled nurses failed to accurately assess and/or document patients' diet requirements for five out of fifteen reviewed. Failure to correctly assess and document the patients' dietary needs placed the patients at risk for receiving inadequate nutrition. Patients: #2, #4, #7, #8, and #11 Findings include: An accurate skilled assessment must include any special diet that the patient has been prescribed to follow by the ordering physician and any teachings or monitoring of the regarding diet patient must be documented in the patient's medical record. Examples of special diets include but are not limited to a diabetic diet, low salt diet, low cholesterol diet, or a heart-healthy diet. This did not occur. 1.) During the review of fifteen clinical records, five revealed inconsistencies in either the assessment, teachings, or monitoring of the patient's doctor ordered diet. a) Patient #2 chart review on 5/18/21 revealed patient diet status not addressed during initial evaluation or on subsequent visits. b) Patient #4 chart review on 5/18/21 revealed doctor's orders for a diabetic (a condition in which the body does not properly process food for use as energy) and no salt diet(control your heart failure symptoms and prevent future heart problems). Patient visit #1 on 4/18/21 by skilled nurse did not note the ordered diet or diet teaching. Patient visit #2 on 4/22/21 by skilled nurse did not note teaching the ordered diet during this visit.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff failed to notify the physician of a patient’s change in status for 1 out of 14 patients reviewed. Failure to notify the physician of change in status placed patients at risk for inadequate interventions and negative health care outcomes. Patients: #8 Findings included: All clinical staff members have the responsibility to communicate changes in the patient's clinical status to the patient's physician to ensure the provision of optimal health services and to prevent adverse outcomes. This did not occur. On 5/18/2021, a review of Patient #8’s record revealed that the patient reported The skilled nurse visit dated 5/6/2021 noted patient as having an oxygen saturation level of 95% with 2 liters of oxygen via nasal cannula (in the nose) and patient requiring oxygen 24 hours per day continuously. Patient #8 was also noted to require teaching on oxygen management and safety. The skilled nurse visit dated 5/11/2021 noted Patient #8 as having an oxygen saturation level of 90% during activity and 96% oxygen saturation on room air. The note mentioned patient experiencing shortness of breath with moderate activity. Patient using 2 liters of oxygen via nasal cannula 12 hours per day. The skilled nurse noted that the patient reported self “tapering” (slowing or stopping the use of the oxygen) the oxygen and using the oxygen when needed. There was no documentation of the physician being notified. When asked, the administrator was unable to provide any further documentation noting the physician being notified.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on the review of the agency's organizational chart and interview with the agency staff on 5/18/2021. A clinical supervisor was not named at the time of this survey. The agency administrator must ensure that a clinical manager is available during all operating hours. This did not occur. Findings include: On review of the agency's organizational chart on 5/18/2021 found that a clinical supervisor for the state of Maryland was not named. When asked, the administrator replied that a clinical supervisor for the Maryland office had not been transitioned in from within the company. This transition did not occur prior to the end of this survey. No other information or documentation was received from the agency staff.