Every finding on record at Albert Home Health Agency Inc

A recertification survey was conducted on 07/26/2022. The census was 1. 0 Licensed and Certified 1 Personal Assistance Services An exit conference was conducted on 07/28/2022. The agency was in compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 07/26/2022. The census was 1. 0 Licensed and Certified 1 Personal Assistance Services An exit conference was conducted on 07/28/2022. Abbreviations: DON = Director of Nursing COVID-19 = Novel Coronavirus SARS – CoV2 OASIS = Outcome Assessment and Information Set ADM = Administrator RN = Registered Nurse QAPI = Quality Assurance and Performance Improvement PAS = Personal Assistance Services PI = Performance Improvement QA = Quality Assurance

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure 2 (Patient 1 and 2) of 2 discharged patient records reviewed who received home health services from the agency received services that were written in an individualized plan of care which was established, periodically reviewed, and signed by a physician. The outcome was the patients received nursing services without signed orders for care from a physician subjecting the patients to poor quality care and increased potential for adverse health outcomes, such as complications from high blood pressures and high levels of pain. During the entrance conference on 07/26/2022 at 11:58 AM the surveyor requested a list of active and discharges clients for the survey period (July 2019 to July 2022), and copies of the plans of care for the client’s chosen for record review. The Administrator stated the agency had no active patients receiving licensed and certified services, and only 2 patients who were discharged during the survey period in 2019. The surveyor requested the clinical records for the 2 discharged patients. A review of the discharged patient list provided by the agency indicated Patient 1 was admitted on 03/29/2019 and discharged on 07/29/2019. Review of the clinical record for Patient 1 revealed no plan of care. The record contained an OASIS recertification assessment dated 05/29/2019, nursing visits signed by the Administrator / RN dated 06/07/2019, 06/14/2019, 06/21/2019, 06/28/2019, 07/05/2019, 07/12/2019, 07/17/2019, 07/26/2019, and an OASIS discharge dated 08/03/2019. The Administrator / RN documented pain levels of 6 on 05/29/2019, 06/07/2019, 06/14/2019, 06/21/2019, 06/28/2019, and a pain level of 7 on 07/12/2019. A review of the discharged patient list provided by the agency indicated Patient 2 was admitted on 04/03/2019 and discharged on 07/30/2019. Review of the clinical record for Patient 2 revealed no plan of care. The record contained nursing visits signed by the Administrator / RN dated 06/14/2019 which documented high blood pressure reading of 160/90, and on 06/20/2019 of 174/96. The surveyor requested the agency policy and procedure manual(s) from the Administrator during the opening conference. The surveyor reviewed the policy and procedure manual provided on 07/26/2022 by the Office Manager. The manual contained no policy for the Plan of Care. An interview was conducted with the Administrator / RN on 07/26/021 at 3:00 PM. The surveyor asked why there were no Plans of Care in the clinical records. The Administrator / RN stated: “the doctors never signed them.” The surveyor asked about the lack of physician signatures on the plans of care. The Administrator / RN stated they didn’t know why the doctors would not send them back that the agency tried to get the doctors to sign them. The surveyor asked for copies of the unsigned plans of care. The Administrator / RN stated they were “in the computer” and they would try to print them out. No plans of care were provided by the end of the survey. The surveyor asked about the outcome of no plans of care in the clinical records. The Administrator / RN stated they didn’t bill for the visits, and the Administrator / RN saw the patients and knew what to do. The surveyor asked if the lack of plans of care could have impacted a patients care if another nurse saw the patient. The Administrator / RN stated the patients had been discharged in 2019. The surveyor asked about the lack of a policy for the Plan of Care. The Administrator / RN stated, “the secretary must have misfiled it.” According to the American Heart Association a normal blood pressure is 120/80 or less, and high blood pressure stage 2 is 140/90 or higher, November 30, 2017. https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure According to Harvard Health Publishing from Harvard Medical School a pain level above 5 indicates severe pain, December 1/2018. https://www.health.harvard.edu/pain/the-pain-of-measuring-pain

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 Performance improvement projects for three of three years of the survey review from July 2019 to July 2022. The outcome was the agency was not focused on determining and completing the required projects. This could potentially affect the care and safety of future clients for the agency. The surveyor requested the QAPI documents for July 2019 to July 2022 during the entrance conference on 07/26/2022 at 11:58 AM. 0n 07/28/22 the surveyor reviewed the QAPI three ring binder provided by the agency Office Manager. Review of the documents provided found the last QAPI activity was dated 2016. There was no evidence of any QAPI activities, and no evidence of performance improvement plans, or activities found for the period of review July 2019 to July 2022. Review of the agency policy and procedures manual provided revealed no policy for performance improvement projects. An interview was conducted with the Administrator on 07/26/2022 at 11:58 AM during the entrance conference. The surveyor provided and reviewed a list of the required documents for the survey. The Administrator stated: “I wasn’t prepared for a survey…. We haven’t done any QAPI because we don’t have any patients. I can let you look at what we used to do when we had patients.” The Administrator stated they were thinking about starting a pediatric program and hiring a pediatric nurse because the agency was not making any money. An interview was conducted with the Administrator and Office Manager on 07/28/2022 at 3:30 PM. The surveyor reviewed the findings of no QAPI and performance improvement projects for July 2019 to July 2022. The Administrator stated the agency used to have a consultant do this but had not done any QA since they didn’t have any patients. The surveyor asked if the agency had discussed, planned, and conducted any performance improvement projects for the last three years. The Administrator stated: “No.” The surveyor asked about the outcome of the agency having no projects planned or performance improvement projects for the last three years. The Office Manger stated the agency wasn’t really operating. The Administrator stated they had been ill and had stopped accepting patients since 2019.