Every finding on record at Advantage Home Health Services, LLC

Based on the findings of an unannounced onsite state re-licensure and Medicare recertification survey completed on December 15, 2023, Advantage Home Health Services 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 unannounced state re-licensure and Medicare recertification survey completed 12/15/23, Advantage Home Health Services LLC, 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.

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 a review of clinical records (CR), agency policy, and staff interviews (EMP), the agency did not administer treatments in accordance with the plan of care for two (2) of fifteen (15) CRs reviewed. (CR2 and CR15) Findings Included: A review of agency policy, “Medical Record Content,” on 12/15/23 at approximately 1:00 pm revealed, “Procedure…4. Each medical record will contain the following: …initial and ongoing assessments, including comprehensive assessment and all assessments of the most recent home health admission…Identification of problems, interventions and goals (care planning) for each discipline and updates to the plan of care…Actions/interventions/procedures…Patient’s response to all interventions, including medication administration, treatments and services and responses to those interventions.” A clinical record review conducted on 12/12/23 at approximately 2:30 pm for CR2: Start of Care (SOC) 11/11/23, Certification period reviewed 11/11/23 – 1/9/24 found: Document titled, “Home Health Care Certification and Plan of Care” signed 11/15/23 read, “SN [skilled nursing]: Assess weight change: report gain of 2 lbs in one day or 5 lbs in one week. SN: Patient/caregiver monitors patient’s weight and weight changes and reports any weight gain to clinician…” CR2 Skilled Nursing Visits for period 11/11/23-12/8/23 revealed the following: 11/20/23: no documented weight assessment 11/24/23: no documented weight assessment. Narrative note reads, “…Pt continues to not have a scale or weigh [themselves]. …” 11/27/23: no documented weight assessment. 12/1/23: no documented weight assessment. Narrative note reads, “…Pt continues to not have a scale or weigh [themselves]. …” 12/4/23: no documented weight assessment. Narrative note reads, “…Pt continues to not have a scale or weigh [themselves]. …” 12/8/23: no documented weight assessment. 12/11/23: no documented weight assessment. Narrative note reads, “…Pt continues to not have a scale or weigh [themselves]. …” An offsite clinical record review conducted on 12/15/23 at approximately 1:00 pm for CR15: SOC: 10/13/23, Certification period reviewed 10/13/23 – 12/11/23 found: Document titled, “Home health Care Certification and Plan of Care” signed 10/18/23 read, “…SN: Assess compliance with CHF treatment and regimen…SN: Patient to weigh self daily and notify MD if gains 2-3 pounds in a day or 5 pounds or more in a week. …” CR15 Skilled Nursing Visits for period 10/13/23-10/23/23 revealed the following: 10/23/23: no documented weight assessment. Narrative note reads, “Patient has not been compliant with daily weights.” The above findings were confirmed with EMP1, VP of Clinical Compliance, during an interview on 12/19/23.

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 supply room observations (OBS), policies, and employee interviews (EMP), the agency did not follow accepted clinical practice to maintain patient safety and prevent infections related to expired and outdated medical supplies for one (1) of one (1) observation. (OBS1) Findings include: Agency policy titled, “Supply Maintenance,” reviewed 12/11/23 read, “Procedure…At the agency site(s)..Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded…” During a tour (OBS1) of the agency’s supply room on 12/11/23 at approximately 9:30 am the following outdated and undated supplies were found: 72 -Vacutainer 4mL clot activator, red top tubes with expiration date of 9/30/23 1 - package of Hand Sanitizing Alcohol wipes with an expiration date of 9/30/2023 2 - Apogee Catheter insertion kits with an expiration date of 6/1/23 1 - CADD administration set with an expiration date of 4/27/23 4 - 22 gauge Insyte Autoguard Winged shielded IV catheters with an expiration date of 10/31/23 1 – Sorba view central line dressing with an expiration date of 11/2023 2 – 2 – small bore extension sets with expiration date of 12/1/23 1 – Vygon PICC removal tray with an expiration date of 10/31/23 69 – urine transfer collection devices, unable to discern expiration date, not in original box, no manufacturer date or expiration date 1 – Bard leg bag unable to discern expiration date 2 – 16 French Kendall/Tyco catheters unable to discern expiration date on packaging 2 – 6.0 mL Vacutainer red top tubes with an expiration date of 9/30/23 4 – 5.0 mL Vacutainer SST tubes with an expiration date of 7/31/23 3 – 4.5 mL Vacutainer PST tubes/gel and lithium heparin with an expiration date of 7/31/23 During an interview on 12/11/23 at approximately 10:30 am the procedure for stocking and reviewing the agency’s supplies was discussed with EMP2, clinical director. EMP2 verified that no system existed at this time for monitoring shelf-life of sterile and nonsterile supplies in undated packaging. The finding of expired supplies was also reviewed on 12/14/23 at approximately 1:30 pm with EMP1, VP of Clinical Compliance.

Based on the findings of an unannounced onsite Medicare Re-certification survey completed February 19, 2021, Advantage Home Health Services, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare Re-certification survey completed February 19, 2021, Advantage Home Health Services, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 record (CR) review and staff (EMP) interview, it was determined that the agency failed to ensure the Plan of Care (POC) contained all disciplines ordered on the referral for two (2) of fourteen (14) CR reviewed. (CR 2 &12). The agency also failed o ensure the POC contained ordered nterventions for one (1) of fourteen (14) CR reviewed (CR5), and supplies for one (1) of fourteen (14) CR reviewed (CR4.) Findings included: Review of agency policy on February 18, 2021 at approximately 11:45 am revealed: "Plan of Care-CMS #485 and Physician Orders...Procedure...4. The individualized plan of care must include the following:...The types of services, supplies, and equipment" required... Review of clinical records on February 12, 2021 between approximately 9:25am and 11:30am, February 16, 2021 between approximately 8:30 am and 2:30 pm, and February 18, 2021 between approximately 1:20 pm and 3:30 pm, and January 8, 2021 between approximately 10:00 am and 11:30 am revealed: CR2, start of service (SOS)1/17/2021, period reviewed 1/17/2021-2/11/2021, CR contained referral to Home Health Agency for aftercare following joint replacement for Nursing, Physical Therapy and Occupational Therapy. Plan of Care (POC) developed upon intial comprehensive assessment did not include Occupational Therapy (OT). No evidence that OT was ordered to evaluate patient. CR4, SOS 1/30/2021, period reviewed 1/30/2021-3/30/2021, CR contained referral to Home Health Agency ordering Accuchecks (blood glucose testing) fout times a day. Plan of CAre (POC) developed upon initial comprehensive assessment also ordered Accuchecks four times a day. No diabetic testing supplies documented on POC. CR5, SOS 2/1/2021, period reviewed 2//2021-4/1/2021, CR revealed POC documentation of Sliding scale insulin to be administered three times a day. Intervention on POC documented "Blood sugar checks as needed per day." Narrative note written by nurse upon initial comprehensive assessment noted staff at facility check blood sugar. POC failed to contain intervention for caregiver to check blood glucose level three times a day to coorelate with sliding scale insulin administration. CR12, SOS 1/18/2021, period reviewed 1/18/2021-2/6/2021, CR contained referral to Home Health Agency for Nursing, Physical Therapy, and Occupational Therapy services. Plan of Care (POC) developed upon intial comprehensive assessment did not include Occupational Therapy (OT). No evidence that OT was ordered to evaluate patient. Findings confirmed in exit interview with Vice President of Quality, Vice President of Operations, and Chief Financial Officer on 2/18/2021 at approximately 12:30 pm confirmed findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, it was determined that the agency failed to ensure verbal orders were signed and dated by ordering physician within 7 days for five (5) of fourteen (14) CR's reviewed. (CR 4, 7, 11, 12, &13) Findings included: Review of agency policy on February 18, 2021 at approximately 11:45 revealed Agency policy to not reflect Pennsylvania State Regulations for physician signature of verbal orders. Policy reads: " Physician Orders-Verbal Orders ...PROCEDURE ...All verbal orders must be subsequently signed by the physician (withing 30 days for CHAP) ... " Interview with Vice Presidency of Operations on February 18, 2021 at approximately 12:00pm revealed that the agency " does not have a formal process for obtaining physician signatures on orders but we usually fax it out once signed by the clinician and if not received back in 5 days we refax it out. " Review of clinical records on February 12, 2021 between approximately 9:25 am and 11:30 am, February 16, 2021 between approximately 8:30 am and 2:30 pm, and February 18, 2021 between approximately 1:20 pm and 3:30 pm, and January 8, 2021 between approximately 10:00 am and 11:30 am revealed: CR4, start of services (SOS) 1/30/2021, period reviewed 1/30/2021-3/30/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/30/2021. As of 2/18/2021 POC not back signed by physician. Documentation reflected POC sent for to physician for signature 2/2/2021 and 2/16/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order. CR7, SOS 6/3/2020, period reviewed 11/30/2020-1/28/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/15/2021. Doctor signature on POC dated 1/27/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order. CR11, SOS 2/29/2020, period reviewed 2/29/2020-3/12/2020, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 2/29/2020. Doctor signature on POC dated 3/11/2020. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order. CR12, SOS 1/18/2021, period reviewed 1/18/2021-2/6/2021, CR contained Plan of Care (POC) with a verbal order date signed by Registered Nurse (RN) on 1/18/2021. Doctor signature on POC dated 1/27/2021. No evidence of multiple attempts to obtain signature within 7 days of receipt of verbal order. CR13, SOS 7/23/2020, period reviewed 7/23/2020-8/7/2020, CR contained Plan of Care (PC) with a verbal order date signed by Registered Nurse (RN) on 7/23/2020. As of 2/18/2021, No physician signature on POC. Documentation reflects POC sent to physician 7/24/2020, 7/30/2020, then monthly for five months 8/14/2020, 9/29/2020, 10/15/2020, 11/16/2020, 12/28/2020, with no evidence of attempts in 2021. Findings confirmed in exit interview with Vice President of Quality, Vice President of Operations, and Chief Financial Officer on 2/18/2021 at approximately 12:30 pm confirmed findings.