Every finding on record at All About Family Inc

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys from 5/14/24 through 5/17/24. Unless otherwise indicated, the general use of the terms "facility" or "facilities" refers to all providers and suppliers affected by this regulation. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. Based upon the findings of the survey, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 5/14/24 through 5/17/24.

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 observation, review of patient medical records and patient and staff interview, the agency failed to revise the plan of care to reflect the required frequency of home health aide visits for 2 of 9 sample patients (#1, #3). The findings were: 1. Observation in the home of resident #1 on 5/15/24 at 10:15 AM showed the patient received home health services that included a registered nurse (RN). Interview with the patient on 5/15/24 at 11:10 AM revealed the patient received Community Choice Waiver (CCW) services from the agency that included nursing Monday-Friday and a home health aide (HHA) weekly. Review of the patient's medical record showed a plan of care (POC) from 3/21/24 to 5/19/24 with orders for a HHA 3-5 times a week. Interview with the director of nursing (DON) on 5/17/24 at 10:50 AM revealed the patient's POC changed in November of 2023 from a HHA 3-5 times a week to weekly and the plan of care had not been updated to reflect the change. 2. Observation in the home of resident #3 on 5/16/24 at 10 AM showed the patient received home health services that included a RN and a HHA. Interview with the patient on 5/16/24 at 9:50 AM revealed the patient had a nurse and aide every morning 5 days a week. Interview with HHA #1 on 5/16/24 at 10:18 AM revealed the patient received a HHA 2 times a day/5 days a week. Review of the patient's POC from 4/19/24 to 6/17/24 showed HHA orders for up to 5 days per week to assist the patient with activities of daily living. Further review showed the POC lacked information related to the frequency of HHA visits (2 times a day) and the specific tasks delegated to the HHA for each home visit. Interview with the DON on 5/17/24 at 10:10 AM confirmed the HHA plan of care needed to be revised to reflect the frequency of the HHA home visits to 2 times a day/5 days a week and reflect the delegated tasks for each home visit.

A recertification survey and a COVID-19 focused infection control survey, which included a review of emergency preparedness requirements was was conducted by Healthcare Licensing and Surveys from 5/24/21 to 5/27/21. The following common abbreviations are used throughout this document: HHA: Home Health Aide OASIS: Outcome and Assessment Information Set POC: Plan of Care RN: Registered 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 medical record review, staff interview, and policy and procedure review, the agency failed to develop a comprehensive POC including all pertinent information for 1 of 7 sample patients (# 6). The findings were: 1. Review of the medical records for patient #6 showed a telephone consult dated 5/1/2020 that read, "family has also decided that patient should be a DO NOT RESUSCITATE". The agency accepted the summary and provider signature as a do not resuscitate (DNR) order. 2. Review of the 4/26/2021 OASIS showed the DNR status was not coded. Review of the admission profile for the certification period of 4/30/21 to 6/28/21 showed the code status was DNR. 3. Review of the Wyoming provider orders for life sustaining treatment (WyoPOLST) form dated 5/18/2020 showed the patient had elected full code. However, the document was not signed by a provider. 4. Interview on 5/25/21 at 4:45 PM with HHA #1 and HHA #2 during a home visit, revealed they believed the patient had elected full code status. 5. Interview with the administrator on 5/26/2021 at 9 AM revealed the telephone order and the WyoPOLST had conflicting information regarding patient code status. 6. Review of policy "Advance Directive Policy" dated 12/2016, stated, "All About Family Inc. has an advanced directives form that is included in the admission packet to be filled out by the patient, guardian, or durable power of attorney upon admission to this home health agency...The directions on the advanced directives will be followed according to the desires. The advance directives ensure that: Each person has the right to make a decision about his or her medical care. These include...Cardiopulmonary Resuscitation, otherwise known as CPR...