Every finding on record at Advantx Home Care Inc

A Recertification Survey entrance conference was conducted on 06/28/2021 at approximately 12:40 PM with the Adm (in person) and the DON (in person). Census: L&CHH: 95 LHH: 0 An exit conference was conducted on 07/01/2021 with the Adm (in person) and the Alternate DON (in person) at 3:30 PM. The preliminary findings were discussed. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited. ABBREVIATIONS Adm - Administrator CFR - Code of Federal Regulations DON -Director of Nurses L&CHH - Licensed and Certified Home Health LHH - Licensed Home Health

A Recertification Survey entrance conference was conducted on 06/28/2021 at approximately 12:40 PM with the Adm (in person) and the DON (in person). Census: L&CHH: 95 LHH: 0 An exit conference was conducted on 07/01/2021 with the Adm (in person) and the Alternate DON (in person) at 3:30 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Deficiencies cited at standard level. ABBREVIATIONS Adm - Administrator CFR - Code of Federal Regulations CNA - Certified Nurse Aide DON - Director of Nurses/Supervising Nurse EMR: electronic medical record FSBS- finger stick blood sugar hha - home health aide HHA - Home Health Agency L&CHH- Licensed and Certified Home Health LHH - Licensed Home Health LVN -Licensed Vocational Nurse PIP - Performance Improvement Project POC - plan of care QAPI- Quality Assurance Performance Improvement rehab - rehabilitation RN - registered nurse SN - skilled nurse

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 record review and interview, the agency failed to develop POC's that covered all required elements for all patients. In three (Patients 1, 2 and 3) of seven active records reviewed, the POC failed to include: Patient 1: Interventions for the SN to assess the patient's blood sugar via FSBS or assessing the blood sugar log, abnormal FSBS parameters to report to the physician, and a complete medication list to include B12. Patient 2: Unacceptable pain levels to report to the physician. Patient 3: Unacceptable pain levels to report to the physician. This failure placed patients at risk for receiving inadequate care, a decline in status, exacerbation of disease process and at risk of subsequent emergency room visits and/or hospital re-admissions. This failure also meant the patient's needs would not be addressed by the physician. Findings Include: Patient 1: Record review of the EMR included a POC for the certification period 03/12/2021 to 05/10/2021 electronically signed by RN A on 03/12/2021 with a primary diagnosis of diabetes mellitus. Review of the entire POC failed to include orders for the SN to assess the patient's blood sugar via FSBS or review of the patient's blood sugar log, abnormal FSBS parameters to report to the physician and a complete medication list to include B12. During an interview on 07/01/2021 at 12:40 PM with the DON and Alternate DON, the surveyor asked why the POC did not include orders for the SN to assess the patient's blood sugar via FSBS or review of the patient's blood sugar log. The DON stated it was overlooked. The surveyor asked why the POC did not include FSBS parameters to report to the physician. The alternate DON stated, "I missed it, it's my bad." The surveyor asked why B12 was not included on the POC's medication list. The DON stated, "Human error." Patient 2: Record review of the EMR included a POC for the certification period 02/23/2021 to 04/23/2021 electronically signed by RN A on 02/25/2021 with a primary diagnosis of fracture of right pubis and secondary diagnosis' of multiple rib fractures and long term (current) use of opiate analgesic [Definition: Opioids are a class of medication used in the management and treatment of pain]. The POC read in part, " ...Patient recently discharged from inpatient rehab after sustaining fall that resulted in multiple fractures of right pelvis and left ribs. Patient has increased pain with ambulation and movement that requires around-the-clock opiate administration to tolerate. Patient also has a pelvic hematoma that causes pain ...Activity causes increased pain related to pelvic and rib fractures ...requires assistance getting in/out of a vehicle as well as loading/unloading walker into/out of vehicle..." Review of the entire POC failed to include evidence of unacceptable pain levels to report to the physician. During an interview on 07/01/2021 at 1:16 PM with the DON and Alternate DON, the surveyor asked why the POC did not include unacceptable pain levels to report to the physician. The Alternate DON stated it was an oversight. The DON stated, " ...I don't see it on here, most of them write that in somewhere." Patient 3: Record review of the EMR included a POC for the certification period 02/22/2021 to 04/22/2021 electronically signed by RN A on 02/22/2021 with a primary diagnosis of hypertensive heart disease without heart failure and a secondary diagnosis of phantom limb syndrome with pain. The POC read in part, " ...has phantom limb pain that increases with ambulation attempts ...requires around-the-clock opiate analgesics to manage pain ..." Review of the entire POC failed to include evidence of unacceptable pain levels to report to the physician. During an interview on 07/01/2021 at 1:53 PM with the DON and Alternate DON, the surveyor asked why the POC did not include unacceptable pain levels to report to the physician. The DON stated Patient 3 goes to a pain management clinic monthly and it does not matter what the pain level is because the physician will not increase the pain medications. Agency policy read in part, " ...Physician Orders/Plan of Care ...Purpose: To ensure that each patient's care is under the direction of the physician ...Procedure ...All orders ...specific to the patient condition and needs ..." Agency Policy read in part, "...Patient Records ...Policy: The agency will establish a record for each patient and maintain each record with the required information according to regulation. Procedure ...1 ...The patient record will include ...current medication list ...physician's orders that include medications ..."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to conduct and document PIP(s) for the calendar years 2018 and 2019 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDE: During an interview with the Adm and the DON on 07/01/21 at 11:30 AM, the surveyor asked if the QAPI binder given to the surveyor included all agency QAPI documents. The DON stated, "Yes, it's not three years, though." The Adm stated, "It's only 1 ¼ years. That's all we have." Record review of the agency's QAPI binder did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018 and 2019. During an interview with the Adm on 07/01/21 at 1:33 PM, the surveyor asked why the agency did not conduct and document a PIP for 2018 and 2019. The Adm stated the agency purchased and started lots of things but nothing was ever completed. Agency Policy read in part, "... Quality Assessment Performance Improvement Plan ...8.001.1 ...Scope ...The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects ..."

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 record review and interviews, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The agency failed to address priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained. The QAPI program was not ongoing and focused on patient outcomes that were measurable. The agency failed to maintain a QAPI Program implemented by a QAPI committee. The agency did not review and update or revise the plan of implementation at least once within a calendar year for the years 2018 and 2019. The governing body failed to ensure that the QAPI Committee met at least twice a year in 2018, 2019 and 2020 to ensure that an ongoing program for quality improvement and patient safety was defined implemented and maintained. This failure could place the agency's patients at risk of negative patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDE: During an interview with the Adm and the DON on 07/01/21 at 11:30 AM, the surveyor asked if the QAPI binder given to the surveyor included all agency QAPI documents. The DON stated, "Yes, it's not three years, though." The Adm stated, "It's only 1 ¼ years. That's all we have." Record review of the QAPI binder included a report titled, " ...QAPI Plan 2020" that was signed and dated by the Adm on 02/07/2020. The report did not contain committee member names. The QAPI binder did not contain any reports, reviews nor documentation that indicated the agency had maintained an agency wide QAPI program that included the federal regulatory requirements, for the years 2018 and 2019. The QAPI Binder did not include any QAPI committee meetings held in 2018, 2019, and 2020. During an interview with the Adm on 07/01/21 at 1:40 PM, the surveyor asked who was on the QAPI Committee. The Adm stated, "We have tried our best." The surveyor asked why the agency had not conducted an annual evaluation of the total operation of the agency for 2018 and 2019. The Adm stated, "There is not a formal one but we did all discuss it." The surveyor asked why the agency had not conducted QAPI meetings twice a year in 2018, 2019, and 2020. The Adm stated, " ...We will do better once I get a better staff and we need to write a better plan of correction ...I'm trying to think, all our meetings were combined together with all the staff and it would not have been considered a QAPI meeting ..." Agency Policy read in part, "... Quality Assessment Performance Improvement Plan ...8.001.1 ... Procedure ...At a minimum, the QAPI Committee must consist of at least (1) the Administrator; (2) the director of nurses; (3) a therapist ... The QAPI Committee must meet at least quarterly and more often if needed ...Program: This QAPI program shall show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care ..."

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that each of the tasks listed at 484.80(b)(3) were evaluated by observation of the hha's performance of the tasks with a patient for three of three hha personnel records reviewed. The required tasks listed at paragraph 484.80(b) (ix), (x), and (xi) include in part: "...(b)(3)(ix) Appropriate and safe techniques in personal hygiene and grooming that include: (A) bed bath; (B) sponge, tub, and shower bath; (C) hair shampooing in sink, tub, and bed; (D) nail and skin care; (E) oral hygiene; (F) toileting and elimination; (b)(3)(x) safe transfer techniques and ambulation; (b)(3)(xi) normal range of motion and positioning;..." This failure placed the patients that receive hha services and any future patients with assigned hha services at risk for receiving substandard or unsafe care from the hha's. Findings Include: Review of an agency report titled "Employee Contact List" provided to the surveyor on 07/01/2021 listed the following hire dates: hha A: 01/21/2020; hha B: 08/18/2020; hha C: 05/14/2021. hha A: Record review of the personnel record included an application for employment signed and dated by hha A on 01/20/2020. The record did not include a competency evaluation. hha A provided hha services for Patient 1 from 03/12/2021-05/10/2021 and Patient 4 from 02/09/2021 to 04/09/2021 reviewed by the surveyor. During an interview on 07/01/2021 at 2:15 PM with the Adm and the DON, the surveyor asked why the personnel record for hha A did not include a competency evaluation. The Adm stated, "She doesn't have one of the skills sheets; I don't think she had one ..." The DON looked in the personnel file and stated a competency evaluation was not included and the agency had some issues with things being filed out of order. hha B: Record review of the personnel record included an application for employment signed and dated by hha B on 08/18/2020. The record included an agency two-page competency evaluation form titled, "Validation of Skills for CNA/HHA" that included hha B's name that was signed and dated on 02/20/2020 by the DON. The form did not include any evidence an RN observed hha B providing a bed bath; sponge, tub, and shower bath; hair shampooing in sink, tub and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation and normal range of motion and positioning with a patient. hha B provided hha services for Patient 2 from 02/23/2021 to 04/23/2021 reviewed by the surveyor. hha C: Record review of the personnel record included an application for employment signed and dated by hha C on 04/29/2021. The record included an agency two-page competency evaluation form titled, "Validation of Skills for CNA/HHA" that included hha C's name and Date of Hire of 04/30/2021 that was signed, but not dated, by the DON. The form did not include any evidence an RN observed hha C providing a bed bath; sponge, tub, and shower bath; hair shampooing in sink, tub and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation and normal range of motion and positioning with a patient. hha C provided hha services for Client 5 from 04/06/2021 to 06/04/2021 reviewed by the surveyor. During an interview on 07/01/2021 at 2:25 PM with the Adm, the surveyor asked why the personnel record for hha B and C did not contain a competency evaluation that included observation of hha B and C's performance of the required tasks by a RN with a patient. The Adm reviewed the personnel files for hha B and C and stated an RN did not complete the form because the tasks performed were simulated tasks and not with an actual person. The surveyor asked why the tasks weren't performed with an actual person. The Adm stated because they were probably done in the office prior to hha B and C going out on the initial visit. The Adm stated the competency forms were new forms for the agency.