Every finding on record at Advanced Personal Care, LLC

Based on the findings of an onsite unannounced Medicare recertification survey completed October 23, 2023, Advanced Home Health was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification survey completed October 23, 2023, Advanced Home Health was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of agency's admission packet containing information given to patients at the start of care, and interviews with staff (EMP), the agency failed to ensure it provided the patient and or caregiver with administrator's contact information, including the administrator's name, business address, and business phone number in order to receive complaints for 17 of 17 records reviewed (CR1-CR17). The agency's admission packet given to patients at start of care was reviewed on October16, 2023, at 11 a.m. The review revealed it did not contain the administrator's name or related contact information. Interviews with EMP1 (COO) and EMP2 (director of nursing) on October 23, 2023, at 12 p.m. confirmed the admission packet is given did not contain the administrator's name and contact information, and that the 17 patients reviewed during the survey would have received it.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), observation during home visits (HV), and staff (EMP) interview, the agency failed to ensure all of the patient's medications were included on the plan of care for five (5) of six (6) records when medications were reviewed during home visits (CR11, CR12, CR14, CR15, & CR17). Review of agency policy on October 23, 2023, at 12:15 p.m. showed: "2.21 PHYSICIAN'S PLAN OF TREATMENT ... A physician's plan of treatment ... must include: ... e. Medications and treatments." "2.54 MEDICATION PROFILE ... Purpose: To ensure all patients have a current list of medications. Policy: The medication list is collectively maintained in the clinical record. The plan of care will demonstrate the patient's current medication regimen ... Agency staff will check all medications a patient may be taking to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, duplicate drug therapy, ... Procedure: 1. The nurse performs ongoing medication monitoring ... 4. The profile will include over-the-counter drugs. ... 6. The patient's clinical record should reflect all medications, ... that the patient is taking both prescription and non-prescription." CR11 contained a physician ordered plan of care with a recertification period from 10/7/2023 to 12/5/2023. Skilled nursing (SN) was ordered to see the patient once a week for assessment and treatment of wounds. Orders included medication profile reconciliation. CR11's home medications, medication profile, and plan of care (medication profile) were reviewed during a home visit conducted on October 17, 2023, at 9:25 a.m. The review revealed that the patient was taking Miralax (laxative) occasionally, Tylenol, Ashwagandha (herbal supplement), and Ibuprofen but the medications were not listed on the CR11's plan of care. Interview with EMP2 (director of nursing) during the home visit confirmed findings. CR12 contained a physician ordered plan of care with a recertification period from 9/19/2023 to 11/17/2023. Physical therapy was ordered to see the patient once a week for strengthening and conditioning. CR12's home medications, medication profile, and plan of care were reviewed with the patient during a home visit conducted on October 17, 2023, at 10:35 a.m. The review revealed the patient was taking a stool softener "occasionally" and two (2) "500 mg" magnesium pills every night, but the medications were not listed on CR12's plan of care. Interviews with EMP2 and EMP4 (physical therapist) during the home visit confirmed findings. CR14 contained a physician ordered plan of care with an initial certification period from 8/28/2023 to 10/26/2023. SN was ordered to see the patient for assessment and treatment of wounds. Orders included medication profile reconciliation. CR14's home medications, medication profile, and plan of care were reviewed with the patient during a home visit conducted on October 18, 2023, at 9:32 a.m. The review revealed the patient was taking extra strength Tylenol 500 mg and a multivitamin, but the medications were not listed on CR14's plan of care. Interview with EMP2 during the home visit confirmed CR14's plan of care did not contain Tylenol or a multivitamin. CR15 contained a physician ordered plan of care with a recertification period from 8/30/2023 to 10/28/2023. SN was ordered to see the patient for assessment and management of heart failure. Orders included medication profile reconciliation. CR15's home medications, medication profile, and plan of care were reviewed with the patient's wife during a home visit conducted on October 18, 2023, at 10:53 a.m. The review revealed the patient was taking fish oil 1200 mg daily, but the medication was not listed on the patient's plan of care. Interview with EMP2 at time of home visit confirmed findings. CR17 contained a physician ordered plan of care with a recertification from 9/12/2023 to 11/10/2023. SN was ordered to see the patient for assessment and management of wounds. Orders included medication reconciliation. CR17's home medications, medication profile, and plan of care were reviewed with the patient during a home visit conducted on October 18, 2023, at 1 p.m. The review revealed the patient was taking Tylenol and Gas-x chewable tablets, but those medications were not listed on the patient's plan of care. Interview with EMP2 during the home visit confirmed findings.

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 agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to promptly notify the physician 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 for three (3) of 12 active records (CR2, CR4, & CR15). Review of agency policy on October 23, 2023, at 12:15 p.m. showed, "2.28 PATIENT NOTIFICATION OF CHANGES ... 1. Any revisions to the plan of care due to a change in the patient's health status will be communicated to ... all physicians issuing order for the plan of care." Review of CR2 on October 17, 2023, at 12 p.m. revealed a physician ordered plan of care with an initial recertification period from 8/31/2023 to 10/29/2023. Skilled nurse was to see patient related to pneumonia and other conditions such as diabetes, "skilled nurse to observe/assess endocrine status for early identification of complications of diabetes. ... licensed professional to report vital signs falling outside the following established parameters. ... [blood pressure greater than 150]." Review of a skilled nurse (SN) visit from 9/8/2023 showed, "Lantus [insulin]-- reviewed dose as he was only taking 2 units and should be taking 5 units." Review of SN visit from 9/26/2023 showed patient's blood pressure was 158/84 and the nurse documented, "PATIENT NOTIFIED MD." Review of SN narrative from same visit showed, "[Patient] went to ED [emergency room] this last weekend for high [blood sugar related to diabetes], spent one night." There was nothing to show SN notified the physician concerning the patient's non-adherence to medication regimen on 9/8/2023, or patient's subsequent hospital admission for high blood sugar, or patient's elevated blood pressure as shown on 9/26/2023 visit note. Review of CR4 on October 19, 2023, at 11:40 a.m. showed a physician ordered plan of care with an initial certification period from 9/12/2023 to 11/10/2023. Skilled nurse was to see patient for care and assessment related to abdominal surgery. Orders included, "[SN] to provide/instruct regarding intervention(s) to monitor and mitigate pain." A SN visit note from 9/19/2023 showed patient had no pain. A SN visit note from 9/26/2023 showed patient rated her pain at 2 and mild (0 to 10 scale with 0 meaning no pain). A SN visit note from 10/3/2023 show patient rated her pain at a 6 with it being a 10 at worse. There was nothing to show SN notified physician concerning the patient's increased pain from 10/3/2023. Patient subsequently admitted to hospital from 10/4 to 10/6/2023 related to severe abdominal pain as noted from 10/8/2023 SN visit, "[Patient] is [status post] [hospital discharge] [related to] severe abdominal pain 10-4-23 to 10-6-23." Review of CR15 on October 23, 2023, at 11 a.m. showed a physician ordered plan of care with a recertification period from 8/30/2023 to 10/28/2023. SN was to see patient for care and management of heart failure. A review of SN notes from two (2) visits on 8/31 and 9/6/2023 showed patient's weight was 204 pounds. A SN note from 9/13/2023 showed patient's weight increased 5 pounds to 209 when compared to the previous visits, "Wife was out of tiwn [sic] earlier this week. ... Caregiver reports patient not taking medications. Hypoglycemia noted in mornings patient very difficult to arouse. Weight increased to 209. Edema +3. Patient refuses to go to ER for further evaluation. SN encourages caregiver to call 911 and send to hospital. Advanced office number left if any questions. Wife is to notify MD of any changes in status." Review of SN coordination note from 9/15/2023 showed patient was admitted to the hospital after the 9/13/2023 SN visit, "SN spoke to wife, reports patient has not yet been discharged as of 9/18 and are unsure of discharge plan moving forward." There was nothing to show SN notified physician of patient's change in condition form the 9/13/2023 visit and his subsequent hospitalization the following day. Interviews with EMP1 (COO) and EMP2 (director of nursing) on October 23, 2023, at 11 a.m. confirmed above findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policy, documentation during home visits, and staff (EMP) interview, the agency failed to provide the patient and or caregiver with a visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA for five (5) of five (5) records reviewed during home visits for the presence of a visit schedule (CR13-CR17). Review of agency policy on October 23, 2023, at 12:16 p.m. showed, "2.27 PATIENT INVOLVEMENT IN THE PLAN OF CARE ... The agency must provide the patient and caregiver with written instructions outlining: Visit schedule, including frequency of visits (schedule of days) by agency personnel and personnel acting on behalf of agency." Review of CR13 during a home visit on October 17, 2023, at 1 p.m. showed a physician ordered plan of care with a recertification period from 9/19/2023 to 11/17/2023. Skilled nursing (SN), physical therapy (PT), occupational therapy (OT), and aide services were ordered. Review of patient's documentation during the home visit did not show that the agency provided the patient with a written visit schedule. EMP2 (director of nursing) was present during the visit and confirmed findings-- no admission packet present in the home. Review of CR14 during a home visit on October 18, 2023, at 9:32 a.m. showed a physician ordered plan of care with an initial certification period from 8/28/2023 to 10/26/2023. SN, PT, and OT services were ordered. Interview with the patient during the home visit confirmed agency did not provide him with a written visit schedule consistent with his most current plan of care. EMP2 was present during the visit and confirmed findings. Review of CR15 during a home visit on October 18, 2023, at 10:45 a.m. showed a physician ordered plan of care with a recertification period from 8/30/2023 to 10/28/2023. SN and OT services were ordered. CR15's wife was interviewed during the home visit, and she confirmed she did not have a written visit schedule, "nothing like that." EMP2 was present during the home visit and confirmed findings. Review of CR16 during a home visit on October 18, 2023, at 11:58 a.m. showed a physician ordered plan of care with a recertification period from 9/23/2023 to 11/21/2023. SN services were ordered. Observation during the home visit revealed no admission packet and no written visit schedule. Interview with EMP2 after the home visit confirmed findings. Review of CR17 during a home visit on October 18, 2023, at 1 p.m. showed a physician ordered plan of care with a recertification from 9/12/2023 to 11/10/2023. SN services were ordered. Observation during the home visit revealed no admission packet in home or written visit schedule. EMP2 was present during a home visit and confirmed findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on review of agency policy, the Center for Disease Control and Prevention (CDC) guidelines, manufacturer directions for use, observations during home visits, and staff (EMP) interview, the agency failed to ensure staff followed accepted standards of practice, used appropriate supply/equipment bags, and followed manufacturer's directions for use for five (5) of seven (7) home visits (HV1, HV2, HV4, HV6, & HV7). According to CDC Guidelines for "Hand Hygiene in the Healthcare Settings," "Glove Use When and How to Wear Gloves ... Change gloves and perform hand hygiene during patient care, if ... moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs." Retrieved from https://www.cdc.gov/handhygiene/providers/index.html Review of agency policy on October 17, 2023, at 9 a.m. showed, "2.78 BAG TECHNIQUE ... Purpose: To maximize infection control and minimize for cross contamination of infectious microorganisms. ALL FIELD STAFF ARE EXPECTED TO: ... 2. To keep bag as clean as possible, bag is to be kept zipped and should be placed in a large plastic storage container with a lid while in the car. ... The most effective form of infection control is good handwashing. Employees must cleanse hands before entering/removing supplies from bag, before examination, and after patient care. ... 7. If additional supplies are needed during the visit, hands are to be cleansed before re-entering the bag. ... 10. All equipment is cleansed with disinfectant after use and before returning to the bag. ... 12. To keep the bag as clean as possible, once a week (or as indicated); the outside of the bag is wiped with a disinfectant solution such as Lysol." Observation during home visit (HV1) at residence of CR11 with EMP2 (director of nursing) and EMP3 (registered nurse) was conducted on October 17, 2023, at 9:25 a.m. EMP3 carried an open supply bag containing patient care items from his/her car into patient's home. The bag had no zipper. During patient care, EMP3 touched patient and his wound dressing multiple times with gloved hands. EMP3 removed his/her gloves several times during the home visit and used hand sanitizer after glove removal but EMP3 kept his/her hand sanitizer inside of his/her open supply bag with other multi-use patient care items, and by doing so failed to ensure his/her hands were disinfected prior to entering the supply bag. When the visit was nearly complete, EMP3 hung his/her supply bag from his/her forearm. With gloved hands, EMP3 wiped equipment with a disinfectant wipe, and without letting the items dry for 2 minutes (see below) or removing gloves, dopped the items into open supply bag one at a time except for his/her stethocscope which he/she placed around his/her neck instead of placing it inside his/her supply bag. Interview with EMP1 and EMP3 after the home visit confirmed above findings. Observation during home visit (HV2) at residence of CR12 with EMP2 and EMP4 (physical therapist) was conducted on October 17, 2023, at 10:35 a.m. EMP4 carried his/her supplies and patient care items used during the home visit with a leather satchel that had no zipper. Interview with EMP2 and EMP4 after the home visit confirmed findings. EMP2 was not sure if a permeable material such as leather could be disinfected as outlined in agency's policy. Observation during home visit (HV4) at residence of CR14 with EMP2 and EMP6 (licensed practical nurse) was conducted on October 18, 2023, at 9:32 a.m. EMP4 assessed the patient with equipment such as blood pressure cuff and stethoscope. EMP4 wiped his/her stethoscope with a disinfectant wipe and before it was dry, he/she placed the stethoscope around his/her neck instead of placing it inside his/her supply bag. EMP4 wiped the remainder of his/her patient care items with a disinfectant wipe but placed them back into his/her supply bag one-by-one without letting items dry for 2 minutes (see below), and without performing hand hygiene. Interview with EMP2 and EMP6 after the home visit confirmed findings. Observation during home visit (HV6) at residence of CR16 with EMP2 and EMP9 (registered nurse) was conducted on October 18, 2023, at 11:58 a.m. EMP9 used equipment on patient such as blood pressure cuff, stethoscope, and thermometer. Once the visit was complete, EMP9 used a disinfectant wipe on each piece of equipment and placed back inside of his/her supply bag without letting dry for 2 minutes (see below) first and without performing hand hygiene. Interview with EMP2 after the home visit confirmed findings. Observation during home visit (HV7) at residence of CR17 with EMP2 and EMP10 (registered nurse) was conducted on October 18, 2023, at 9:32 a.m., and revealed EMP10 use one pair of gloves for the entire wound care procedure with expired patient care items. EMP10 removed patient's soiled dressing with gloved hands and discarded. With same gloved hands, EMP10 reached into a box containing patient's clean supplies and removed 2x2 dressing from an already torn-open paper container. From the same cardboard container, EMP10 also retrieved a bottle of "Sterile Water for Irrigation, USP 1000 mL [US Pharmacopia 1000 milliliters] from the same large cardboard box. The bottle was already opened and approximately half empty. EMP10 used the liquid contained in the bottle to cleanse patient's wound. Further review of the bottle's label with EMP2 showed, "No microbial agent or other substance has been added. ... Do not use unless ... seal is intact. Discard unused portion." Interview with EMP2 and EMP10 confirmed findings. EMP10 was asked how long the bottle had been open for and he/she noted, "a week or so." The directions for use for the disinfectant wipes used during HV1, HV4, and HV4 were reviewed with EMP2 and EMP6 on October 18, 2023, at 10 a.m., and they confirmed a 2-minute contact time when items to be disinfected are to remain wet, "Sani-Cloth ... GERMICIDAL DISPOSABLE WIPE ... To disinfect ... wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes."