Every finding on record at Altimate Care, LLC

Extended Survey/ Substantial Allegation 31955 The following deficiencies are based upon the substantial allegation 31955 completed on10/14/21. Altimate Care LLC., 368350, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agency. Altimate Care LLC., 368350, is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey. Locations: Parent: 20515 Shaker East Boulevard Shaker Heights, Ohio 44122 Branches: 921 Eastwind Dr., Suite 129 Westerville, Ohio 43081 40 Central Center Chillicothe, Ohio 45601 24 S. Clay St., Suite B Millersburg, Ohio 44654

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on medical record review, staff interview, physician interview, and policy review, the agency failed to follow the physician ordered plan of care and failed to notify the physician of a significant change in a patient's condition. (G0590).

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, physician interview, and policy review, the agency failed to follow the physician ordered plan of care and failed to notify the physician of a significant change in a patient's condition. This affected one (Patient #1) of three patient whose records were reviewed for change of condition. This had the potential to affect all 276 patients receiving services at the agency. Findings include: Findings include: Medical record review revealed Patient #1 had a start of care date of 06/07/17. Diagnosis included chronic Kidney disease dependent on dialysis, diabetes mellitus, and osteochondritis dissecans of unspecified site. Osteochondritis is defined as a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. For the certification period of 01/17/21 to 03/17/21 the physician ordered plan of care included skilled nursing (SN) for observation/assessment of pain, effectiveness of pain management regimen and skilled nursing related to pain management. The SN was to intervene to minimize complications if pain levels increased. Review of the SN note dated 03/15/21 revealed the SN documented Patient #1 reported he had been dropped at the dialysis center by technicians during a chair to gurney transfer. The patient reported he had been dropped on his left hip and was experiencing intense pain since the incident. The aide reported the patient was unable to perform certain duties due to pain. Patient #1 reported the pain level at eight out of a scale of one to ten. Patient #1 also reported he was having trouble urinating and thought he might have a urinary tract infection. The SN instructed Patient #1 to report his concerns to the physician at his appointment on Wednesday, 03/17/21, which was two days later. The record was silent for the SN reporting the patient’s report of being dropped, his increased pain level or problems with urination to the physician. Interview on 0/12/21 at 12:31 PM, Staff A stated Patient #1 was dropped by the ambulance company during a transfer. Staff A stated the SN (Staff X) saw Patient #1, noted he reported he had been dropped, and had pain of a level eight out of ten, which was unusual for the patient. Patient #1 had a virtual appointment the next day with the physician. Staff X instructed Patient #1 to tell the physician about his pain during his appointment. At the appointment Patient #1 did not tell the physician he had been dropped. Staff A verified Staff X should have called the physician about the change of condition. Interview on 10/13/21 at 3:36 PM, Patient #1’s physician was interviewed via telephone. The physician stated he was never told of Patient #1 being dropped or any increase in pain. The physician revealed he felt the injury may have led to Patient #1’s decline and death as he was in too much pain to continue medical care, including dialysis. Review of the agency policy titled "Plan of Care-CMS #485 and Physician/Practitioners Orders" revealed it was agency policy for SN and other home health services to be in accordance with a Plan of Care based on patient’s diagnosis and assessment of immediate and long-range needs and resources. This deficiency substantiates Complaint Number 31955.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on medical record review, review of emails, review of Patient Consulting Group (PCG) report, staff interview, and review of facility protocols, the agency failed to communicate effectively between the parent and branch location regarding an allegation of negligence involving one (#1) patient (G0940).

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on medical record review, review of emails, review of Patient Consulting Group (PCG) report, staff interview, and review of facility protocols, the agency failed to communicate effectively between the parent and branch location regarding an allegation of negligence involving one (Patient #1) out of three patients reviewed for change of condition. This had the potential to affect all 276 patients receiving services at the agency. Findings include: Medical record review revealed Patient #1 had a start of care date of 06/07/17. Diagnosis included chronic Kidney disease dependent on dialysis, diabetes mellitus, and osteochondritis dissecans of unspecified site. Review of the skilled nursing (SN) note dated 03/15/21 revealed the Staff X documented Patient #1 reported he had been dropped at the dialysis center by technicians during a chair to gurney transfer. The patient reported he had been dropped on his left hip and was experiencing intense pain since the incident. The aide reported the patient was unable to perform certain duties due to pain. Patient #1 reported the pain level at eight out of a scale of one to ten. The SN instructed Patient #1 to report his concerns to the physician at his appointment on Wednesday, 03/17/21, which was two days later. Review of emails dated 05/18/21 and 06/15/21 revealed the PCG had emailed the Columbus branch office requesting documentation from Patient #1's record. Review of an email dated 09/16/21 from to Staff Y, office manager of the Columbus branch office, revealed the PCG Incident Investigator's report was emailed to Staff A. The report indicated an investigation had been substantiated regarding Patient #1 for unexplained death, neglect, and services delivered without or not in accordance to physician orders. The report revealed on 03/20/21, Patient #1 reported to the emergency room with complaints of pain. The patient reported to the emergency room physician he had been dropped. The computerized tomography (CT) scan revealed the patient had a lumbar (L) 4 burst fracture and transverse process fractures to the right L3 and L4. Interviews on 0/12/21 at 12:31 PM and 1:14 PM, Staff A verified Patient #1 was dropped by the ambulance company during a transport and did not go get help. Staff A stated Staff X saw Patient #1, noted he had pain at an eight out of 10, which was unusual for the patient. Staff X noted the patient was dropped and he had a virtual appointment the next day with the physician. Staff X instructed Patient #1 to tell the physician during his appointment about his pain. At the appointment Patient #1 did not tell the physician he had been dropped. Staff A stated Staff X should have called the physician. Staff A, the parent location's Clinical Director, stated the office at the Columbus branch location knew about the situation but did not inform Staff A about incident. Staff A reported she did not know anything about this incident until she received the PCG final report in September 2021, at which time she began an investigation. Staff A stated she believed this incident was gross neglect of a patient. The patient quit going to dialysis because he was in so much pain. Staff A stated when she was notified in September 2021 of the incident she tried to fire Staff Y and Staff X, but everything went to the lawyer. Staff X continued seeing patients after this incident until he was terminated on 10/11/21. Staff X was not fired until the PCG allegation was substantiated, the parent company was notified of the incident, and the company's legal team gave the company the approval to terminate Staff X. There has been no reeducation to other staff members and Staff X continued to work without education until his termination on 10/11/21. On 10/12/21 at 1:04 PM Staff Y stated the agency got the request from the PCG for medical records in May 2021 for the death protocol and another request in June 2021. The PCG gave the agency the outcome of the investigation in September 2021. Staff X was fired yesterday for refusing to come in and talk about the incident with Patient #1. No audit of records were done that she was aware of. The branch location was on their third nurse manager since the incident occurred in March 2021 with Patient #1. Review of an email dated 09/17/21 from Staff A to the company’s owner and cc’d to the Regional Director of Operations (RDO) revealed Staff A documented Staff Y knew about Patient #1’s fall since the occurrence and never advised her or the RDO of the incident. Staff Y did not inform Staff A of what had transpired until 09/16/21 when the new Branch Manager, Staff K, told Staff Y, she should call Staff A and let her know. The PCG had already placed a referral to the State Board of Nursing regarding Staff X. The email indicated Staff X and Staff Y should be terminated effective immediately because of negligence and their part to hide the incident and cover up. The email indicated when Human Resources and Staff A spoke to the PCG, the PCG investigator reported when she asked Staff Y what the agency was going to do to rectify this situation, Staff Y stated re-educate the nurse. Staff A documented, “I want to be clear; no one has the authority to deal with PCG except for the RDO or myself. According to our handbook, this would fall under Standards of Conduct. This is so egregious, that this is a cause for termination for both in employees. Staff Y was just suspended three days without pay. Please see the highlighted section of the attachment. I ask respectfully requesting a swift answer as we are on borrowed time and I still have education I need to provide to our entire staff." Review of an undated document attached to the email revealed a section titled "Standards of Conduct" which revealed the agency’s standards of conduct included employees will follow all the company policies, procedures, and practices. To ensure orderly operations and provide the best possible work environment, as well as, ensuring the safety of our employees and clients and quality of our treatment services, the agency expected employees to follow rules of conduct that will protect the interests and safety of all employees and the agency. The agency listed examples of infractions of rules of conduct that may result in disciplinary action that shall include verbal and/or written warning, or suspension from work, with or without pay, or termination of employment including: Negligence or improper conduct leading to damage of employer-owned or consumer owned property. This deficiency substantiates Complaint Number 31955.

At the time of the emergency preparedness survey completed on 06/09/21, AltimatecHome Care Inc., 368250 is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey Covid 19 Focus Infection Control Survey The following deficiencies are based on the partial extended recertification survey completed 06/09/21. Altimate Home Care Inc., 368250, is not in compliance with the requirements found at Home Health Agency 42 CFR Part 484, Subpart B, C. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at Home Health Agency 42 CFR Part 484.70 related to Infection Control and 42 CFR Part 484.102(b)(5) related to Emergency Preparedness. Locations: Parent: 20515 Shaker East Boulevard Shaker Heights, Ohio 44122 Branches: 921 Eastwind Dr., Suite 129 Westerville, Ohio 43081 40 Central Center Chillicothe, Ohio 45601 24 S. Clay St., Suite B Millersburg, Ohio 44654

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 medical record review, patient and staff interview, and policy review, the agency failed to maintain an accurate list of medications for one (Patient #1) of four patients who had a home visit conducted. The total sample was 10 patients. Findings include: Medical record review revealed Patient #1 was admitted to the agency on 04/23/21. Review of the hospital discharge paperwork dated 04/22/21 revealed Patient #1 was prescribed prednisone (steroid) drops to use one drop four times daily. The 04/22/21 hospital discharge also revealed Patient #1 was to take the diuretic Lasix 40 milligrams (mg) one time a day. On 06/08/21 at 9:30 AM a home visit was conducted with Patient #1 and Staff B. Interview with Patient #1 revealed she had eye drops and she was now on Lasix 80 mg ever since she got out of the hospital. Review of the client medication report printed out on 06/07/21 revealed there were no eye drops listed and the Lasix dosage was listed as 20 mg daily. Review of an undated agency policy titled "Medication Reconciliation" revealed at the time of admission the admitting clinician would create and document a complete list of medications the patient is taking at home, including dose, strength, route and frequency and the medication list would be updated with each medication change. Interview on 06/08/21 at 4:18 PM Staff A confirmed the eye drops were never added to the medication list and the dosage of Lasix was incorrect on the medication list.

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 medical record review, patient interview, and staff interview, the agency failed to follow the physician's orders for wound care and a Physical Therapy evaluation for one (Patient #1) out of 10 patients sampled. Findings include: On 06/08/21 at 9:30 AM a home visit was conducted with Patient #1 and Staff B. During an interview Patient #1 stated her toe wound was being treated by the wound clinic. Medical record review revealed Patient #1 was admitted to the agency on 04/23/21. Review of Patient #1's physician's ordered plan of care for the certification period of 04/23/21 to 06/21/21 revealed the Skilled Nurse (SN) was to perform/teach pressure ulcer care to the left great toe daily. The record revealed the SN was only seeing Patient #1 one time per week. Review of the SN documentation from 04/23/21 to 06/08/21 revealed the record was absent for any mention of the wound clinic caring for the wound. Review of the medical record revealed a physician's order dated 05/28/21 revealed Patient #1 was to have Physical Therapy (PT) evaluation on 05/30/21 for strengthening and increased mobility. The medical record did not have a PT evaluation when reviewed on 06/08/21. Interview on 06/08/21 at 4:18 PM, Staff A confirmed the PT evaluation had not been completed.