Every finding on record at Aging Well Health Care LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 02/06/2024. During the survey, it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A standard survey for Medicare recertification for the home health provider was completed on 02/06/2024. The provider had 269 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, home visit observation, and interview, the provider failed to ensure a complete and accurate review of all medications were completed in one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Findings included: Review of the provider’s policy,” Medication, Regimen Review Comprehensive, “last revised 03/2023, showed in part the following: - The Registered Nurse (RN) will be responsible for monitoring the patient's medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient's care; - All required comprehensive assessments will include a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy; - At the time of admission an accurate, current, and complete list of all prescription and over-the­ counter (OTC) medications, as well as herbal medications, taken by the patient will be maintained on the medication profile; - Every effort will be made to reconcile any discrepancies with the physician or designee the next calendar day of the assessment; - The clinician will document this contact and any difficulties experienced in obtaining physician response. The clinician will notify the Director of Home Health Clinical Manager if there is no response from the physician on medication reconciliation. If provider staff other than the clinician responsible for completing the patient’s Start of Care (SOC) or Resumption of Care (ROC) Outcome and Assessment Information Set (OASIS) contacted the physician to follow up on clinically significant medication issues, this information must be communicated to the clinician responsible for the SOC/ROC OASIS assessment, so that the OASIS appropriate response may be selected. This collaboration does not violate the requirement that the comprehensive patient assessment is the responsibility of and must ultimately be completed by one clinician; - The medication profile will be placed in a highly visible place and include essential information about dosages, drug schedules, immunizations, and drug allergies. This medication profile will also include the medication action/classification, dosage administration schedule, route, initial order, and discontinuation dates, where applicable and if drug is new (N) or changed (C); - Nursing staff will assess on an ongoing basis the patient's response to the medication and the patient/caregiver's compliance with the medication regimen to include the appropriateness of the medication, adverse patient response, lack of patient response, and/or compliance concerns will be communicated to the physician as well as documented in the clinical record; - Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver; and - The review of medications will be on-going but done a minimum of every 60 days. The clinician will communicate a complete list of the patient's medications to the next service provider when the patient is referred or transferred to another setting service, practitioner, or level of care within or outside the organization. The communication is documented in the clinical record. An updated version of the medication list will be provided in a timely manner to the patient following any changes, and prior to discharge from the provider. RECORD/PATIENT #2: Review of the clinical record showed the patient was re-admitted to home health services on 12/22/2024, following a hospitalization to treat acute respiratory failure, pneumonia (infection of the lung ), and also had diagnoses which included chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes ( a chronic, metabolic disease characterized by elevated levels of blood sugar and depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest. Review of the most current medication list provided by the provider, showed an active order for Desipramine (antidepressant and nerve medication) 25 milligram (mg) two tablets to be taken nightly for mood. Observation and interview on 02/06/2024 at 3:30 PM, during the patient's home visit, showed the following medication discrepancy: Desipramine 25 mg two tablets to be taken nightly for mood. The patient stated that he/she had taken prior to going to the hospital, but hadn't taken any since returning home on 12/22/2024 following a discussion with his/her physician. During an interview conducted on 02/06/2024 at 3:40 PM, RN-A stated the following: - The patient’s current medication profile showed Desipramine 25 mg tablets, 2 tablets to be taken nightly for mood and the order status marked as active; and - He/she would get all the discrepancies clarified. During an interview on 02/06/2024 starting at 3:30 PM the Clinical Manager the following: - The staff are responsible to ensure each patient’s medication reconciliation is accurate when comparing the provider’s medication list to the medication (s) the patient is currently taking in the home; and - The staff are responsible for clarifying and resolving all medication discrepancies with the patient’s physician, to ensure accuracy of medication on the profile list are those medications taken by the patient.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 08/11/2021. During the survey it was determined that AW Health Care is in compliance with the requirements of 42 CFR 418.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for AW Health Care was completed on 08/11/21. The agency had 586 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency admission packet, and interview, the agency failed to assure that the patients be advised, orally and in writing, of the extent to which payment for HHA services may be expected. This deficient practice has the potential to affect the rights of all the agency patients. Findings included: Review of the agency admission packet, provided to patients at the time of admission, showed the document dated 01/13/2018 and titled, "Home Health Condition of Participation: Patient Rights," failed to contain the statement that the patient would be notified, "verbally and in writing," of the extent to which payment for HHA services may be expected. During an interview on 08/09/2021 at 04:10 PM, the administrator confirmed that the patient rights information provided to patients at time of admission failed to include the statement that the patient be notified, "orally and in writing."

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, clinical record review, and interview, the agency failed to ensure an accurate medication review and/or update of the patient's medications was completed in two (Records/Patients #2 and #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 08/2017 and titled, "Medication, Regimen Review Comprehensive," showed that: - All required comprehensive assessments will include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The agency may assign a registered nurse to perform the review when the OASIS is completed by a qualified therapist; - The clinician will ask the patient to describe or confirm any prescription medications, over the counter medications, vitamins, herbs or other supplements, as well as their perceptions about any side effects, and efficacy; and - Review of medications will be on-going, but done a minimum of every 60 days. RECORD/PATIENT #2: During the patient's home visit observation on 08/09/2021 beginning at 3:00 PM, review of the patient's home medication showed the following discrepancies with the agency's current medication profile: - Lantus (decreases blood sugar) OptiClik Cartridge 100 units/milliliter (ml) eight (8) units subcutaneous (beneath the skin) at bedtime; patient stated that "when I feel my blood sugar is up, I take 33 units at bedtime". Caregiver (cg) stated that the nurse practitioner had changed the dose to 8 units, but cg also stated that he/she was usually in bed when the patient took his/her insulin; and - Bottle of nitroglycerin (controls chest pain) was found at the patient's bedside with a prescription date of 01/19/2021, agency medication list showed no order for the nitroglycerin. During an interview with the physical therapist (PT) during the home visit observation, the PT verified that the medication list failed to list nitroglycerin and verified the insulin dosage. There was no further information. RECORD/PATIENT #3: During the patient's home visit observation on 08/10/2021 beginning at 2:15 PM, review of the patient's home medication showed the following discrepancies with the agency's current medication profile: - Allopurinal (treatment of gout - joint swelling) agency medication profile showed 300 milligrams (mg) daily, patient's medication bottle showed 100 mg daily. Patient stated that the physician had increased the medication to 500 mg daily last week; - Colchicine (anti-gout) 0.6 mg agency medication profile showed twice daily. Patient stated that he/she only takes the medication as needed; - Medication found in the home and not included on the agency medication list were: ibuprofen (pain relief), patient stated that he/she takes this medication as needed for pain in his/her legs, potassium chloride (mineral supplement) 10 milliequivalent (meq) tablets taken with food, patient stated that he/she takes once a day, and nystatin (antifungal) topical ointment, patient stated that he/she used on abdominal folds as needed for irritation. During an interview at the time of medication observation, the occupational therapist (OT) concurred with the medication findings. The OT stated that he/she could not explain the medication discrepancies. OT stated that the medication are all reviewed at the start of care. The OT concurred that there was no registered nurse (RN) reconciliation of the medication profile.

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 policy review, clinical record review, observation, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements for two (Records/Patients #2, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 08/2017 and titled, "Plan of Care," showed that an individualized plan of care (POC) is developed utilizing the comprehensive and initial assessment, as well as, information provided by members of the interdisciplinary team and the physician that identified patient specific, measurable outcomes and goals; and is established, periodically reviewed, and signed by doctor of medicine, osteopathy, or podiatry acting within the scope of his/her state license, certification, or registration. The POC must include, at a minimum, the types of services, supplies, all treatments, equipment required; and orders for therapy services, including specific procedure and modalities to be used. RECORD/PATIENT #2: Review of the POC dated 06/23/2021 through 08/21/2021 showed: - Diagnoses included but not limited to type 2 diabetes mellitus (a disease caused by an Insulin (hormone) deficiency and characterized by excess sugar in the blood and urine) with diabetic chronic kidney; - Durable medical equipment included but not limited to: cane, grab bars, tub/shower bench, walker, and wheel chair; - Management of Injectable medications assessment on admission stated "patient unable to take injectable medication unless administered by another person"; - The POC did not include medical equipment/supplies for blood glucose (sugar) monitoring; - The POC did not include parameters for blood glucose levels, and when to notify the physician of abnormal results; and - The POC did not include assessment and/or teaching of patient's self-administration of insulin. During a home visit observation and interview on 08/09/2021 beginning at 3:00 PM, the patient showed physical therapist (PT) how he/she monitored his/her glucose. Patient used a Freestyle meter (device placed on the patient's skin that measured glucose readings by tracking the sensor placed under the patient's skin). Patient placed the meter on the backside of his/her upper arm and obtained a glucose reading. During an interview with the administrator on 08/11/2021 at approximately 10:00 AM, findings were reviewed with the administrator and no further information was provided. RECORD/PATIENT #4: Review of clinical record showed the patient was admitted to home health services on 05/04/2021 for wound management, long-term urinary catheter (a device placed in the bladder to allow drainage of urine) management and a colostomy (a surgical opening of the bowel that allows bowel movements to collect into a bag attached to the skin of the abdomen). The patient began a second certification period on 07/03/2021. EXAMPLE #1: Review of the follow-up comprehensive assessment for recertification dated 07/02/2021 showed that: - The patient had a colostomy; - The presence of the urinary catheter; and - Wound assessments and wound care for the following: * A wound on the coccyx labeled as, "Wound #1," * A wound on the left heel labeled as, "Wound #2,"; * A wound on the top of the left foot labeled as, "Wound 4,"; * A wound on the right outer ankle labeled as, "Wound #5." The POC dated 07/03/2021, and signed by the physician 07/29/2021, failed to contain orders for the care and management of and/or supplies for: - The colostomy; - The urinary catheter including parameters for when to perform catheter irrigation; and - The care of Wounds #1, #2, #4, and #5. The findings were reviewed with the administrator and clinical director and orders to correct the POC were written 08/10/2021 at 05:44 PM EXAMPLE #2: On 07/07/2021 an interim order for wound care to the left heel (Wound #2) showed the nurse was to cleanse the wound with mild soap and water or wound cleanser and dry gauze, zinc oxide to periwound area, apply hydrofera blue (a gentian violet/methylene blue (gv/mb) impregnated antibacterial foam used to create a negative pressure wound environment in deep or tunneling wounds) or hydrofera blue ready (a gv/mb impregnated foam used to treat shallow wounds) to wound bed, and cover with an abdominal pad and secure with tape. Wound care to be done one time per day. SN to do wound care at visit and caregiver to do wound care in skilled nurse (SN) absence. The order failed to contain specific parameters for the use of hydrofera blue or hydrofera blue ready. The findings were reviewed with the administrator and clinical director and orders to correct the POC were written 08/10/2021 at 05:57 PM.

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 record review, home visit observation, and interview, the agency failed to ensure each patient received written information related to visit schedule/instructions in one (Record/Patient #3) of three home visits made. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/19/2021 with bilateral osteoarthritis (a common form of arthritis marked by cartilage degeneration and bone enlargement). Review of the plan of care (POC) dated 07/19/2021 through 09/16/2021, showed that the physician ordered: - Occupational therapy (OT) one week one starting from 07/19/2021; - Physical therapy (PT) one week one starting from 07/19/2021; - OT two times a week for four weeks starting from 08/01/2021; and - PT two times a week for three weeks starting from 07/30/2021. The home visit made on 08/10/2021 starting at 2:15 PM, showed the home folder was reviewed and the agency failed to provide a written frequency of visits for OT and PT. During an interview at the time of the home visit with the OT, he/she stated that all disciplines should document visit schedule in the patient's folder on the calendar provided when a visit would be done.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and interview, the agency failed to provide services that were ordered by the physician as indicated in the plan of care in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect the provision of care to all patients served by the agency. Findings included: Review of agency policy dated 08/2017 and titled, "Description of Services, Skilled Professional Service," showed that the skilled professional must assume responsibility for, but not restricted to provision of services ordered by the physician as indicated in the plan of care. PATIENT/RECORD #2: Review of the clinical record showed the patient was admitted to home health services on 06/23/2021 with a pertinent diagnosis of congestive heart failure (CHF - a syndrome in which the heart is unable to sufficiently pump enough blood to supply the body's metabolic needs). Review of the visit schedule showed: - Skilled nursing to visit one week one, starting 06/23/2021 and then two week one starting on 06/27/2021; - Occupational therapy (OT) one week one starting from 06/23/2021 and then one week one for four weeks; and - Physical therapy (PT) one week one starting 06/23/2021 and then two week two starting 06/27/2021, then one week one, two week two and one week one starting 07/18/2021; - General care for cardiovascular (heart/CHF) system showed instruct/educate on monitoring weight and report gain of three pounds in one day and/or five pounds in seven days, to assess for fluid retention. - Three of three OT notes showed under CHF protocol - not applicable. OT failed to assess patient compliance for weight monitoring and/or assess for fluid retention; and - Eight of eight PT notes showed under CHF protocol - not applicable. PT failed to assess patient compliance for weight monitoring and/or assess for fluid retention. During an interview with the administrator on 08/11/2021 at approximately 10:00 AM, the administrator concurred with the findings. No additional information was provided.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency process policy and clinical record review the agency failed to assure that skilled professional services clinical notes contained documentation according to agency policy in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect the documentation of all of the agency patients. Findings included: Review of agency policy dated 08/2017 and titled, "Description of Services Policy, Skilled Nursing," showed that: - The registered nurse was responsible to keep current and adequate documentation showing assessment of the patient's current status, response to treatment, teaching and training, and the treatments provided; and - The licensed practical nurse was responsible to prepare current and accurate documentation of treatments, teaching and training, observations, patient responses, and reports to the registered nurse. RECORD/PATIENT #4: Review of clinical record showed the patient was admitted to home health services on 05/04/2021 for wound management, long-term urinary catheter (a device placed in the bladder to allow drainage of urine) management and a colostomy (a surgical opening of the bowel that allows bowel movements to collect into a bag attached to the skin of the abdomen). The patient began a second certification period on 07/03/2021. Review of interim physician's order dated 07/07/2021 showed care of the wound on the left heel (Wound #2) included cleansing of the wound with mild soap and water or wound cleanser and dry gauze, zinc oxide to periwound area, apply hydrofera blue (a gentian violet/methylene blue (gv/mb) impregnated antibacterial foam used to create a negative pressure wound environment in deep or tunneling wounds) or hydrofera blue ready (a gv/mb impregnated foam used to treat shallow wounds) to wound bed, and cover with dry dressing and secure with kerlex. The wound care was to be done one time per day. Review of nursing visits on 07/09/21, 07/12/21, 07/16/21 showed the nurse documented wound care. "as ordered," however each visit failed to identify whether hydrofera blue or hydrofera blue ready was used to dress wound #2. The findings were reviewed with the administrator and clinical director and orders to correct the POC were written 08/10/2021 at 05:57 PM.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on agency policy, review of contractual agreement, and interview, the agency failed to assure that the contract for therapy services contained the statement that the agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare or Medicaid billing privileges revoked, or (iv) Been debarred from participating in any government program in one (CONTRACT #1) of one contract reviewed. This deficient practice has the potential to affect the contracted services for all of the agency patients. Findings included: Review of agency undated policy titled, "Contractual Agreement," showed that, "contracts will be reviewed on an annual basis for relevancy, process, rates, and effectiveness of the care, service, and/or products." Review of the contract dated 07/02/10 and titled, "Agreement for Therapy Services," showed the contract failed to contain the statement that the agency would be notified if the contractor had been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare or Medicaid billing privileges revoked, or (iv) Been debarred from participating in any government program. During an interview on 08/09/2021 at 04:10 PM, the administrator stated that they had created an addendum to the therapy contract to contain the statement that the agency would be notified if the contractor had been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare or Medicaid billing privileges revoked, or (iv) Been debarred from participating in any government program., but have not had the addendum signed by the contracted provider.