Every finding on record at Ambassador Home Health Services, LLC

Emergency Preparedness Survey The following deficiency is based on the emergency preparedness survey completed 03/24/21.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure emergency preparedness policies addressed how to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment for seven of seven patients reviewed (Patient #1, #2, #3, #4, #5, #6, and #7). This had the potential to affect all patients receiving services from the agency. The agency's census was 37 patients. Findings include: A review of the facility's emergency preparedness program was completed on 03/24/21. Review of the agency's hazard vulnerability assessment revealed a moderate risk for flooding with a moderate degree of disruption. The review revealed a system of priority classification for patients that had four levels with level four being the lowest (visits could be postponed 72 hours or more) to level one being the highest wherein the patient must have uninterrupted services. Further review of the classification system did not reveal how patients' mobility status was used in determining the patient's level of classification. Review of Patient #1, #2, #3, #4, #5, #6, and #7's clinical record did not reveal at what level each was classified. On 03/24/21 at 2:50 PM in an interview, Staff D was informed of the mobility issue with the classification system, and asked what was the classification for each patient on sample. She said she would look for it. On 03/24/21 at 4:07 PM the surveyor met with Staff D. Staff D did not present additional information on the classification system. On 03/24/21 at 4:25 PM another meeting was held with Staff D. Staff D could not present additional information on the classification system. On 03/24/21 at 4:45 PM an exit conference was held and no additional information on the classification system given.

Partial Extended Recertification Survey COVID 19 Focused Infection Control Survey The following deficiencies are based on the partial extended recertification survey completed 03/24/21. Ambassador Home Health Services 368201, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to perform a comprehensive assessment within 48 hours of the patient's return home from a hospital admission of 24 hours or more for any reason other than diagnostic testing for one of seven sampled patients (Patient #3). The census was 37 patients. Findings include: The medical record review for Patient #3 was competed on 03/24/21. The medical record review revealed the patient's care began with the agency on 01/28/21. The plan of care for the certification period beginning 08/21/2020 revealed the patient was diagnosed with SARS-CoV-2-19, weakness, hypertension, and dementia. The agency was directed to provide weekly skilled nurse visits and physical therapy and occupational therapy to evaluate and treat. The medical record review revealed a communication record dated 02/22/21 from the occupational therapist that stated, "Patient admitted to [local] hospital 2/18-2/20/21". The medical record review revealed visits resumed on 02/22/21. There was no evidence a comprehensive assessment was completed upon the patient's return from the hospital. On 03/24/21 at 2:50 PM in an interview, Staff D was informed of the missing assessment. She said she would look for it. On 03/24/21 at 4:07 PM the surveyor met with Staff D. Staff D could not present the assessment. On 03/24/21 at 4:25 PM another meeting was held with Staff D. Staff D could not present the assessment. On 03/24/21 at 4:45 PM an exit conference was held and no assessment was presented.

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 interview and document review, the facility failed to provide home health services as written in the plan of care for two of seven patients reviewed (Patient #2 and #1). The census was 37 patients. Findings include: 1. The medical record review for Patient #2 was completed on 03/24/21. The medical record review revealed the patient's care began with the agency on 08/30/19. The plan of care for the certification period beginning 02/20/21 revealed the patient was diagnosed with congestive heart failure, hypertension, and type two diabetes mellitus. The agency was directed to provide skilled nurse visits seven times a week. The medical record review revealed for the week of 02/21/21 five skilled nurse visits were made, the week of 02/28/21 three skilled nurse visits were made, and for the week of 03/07/21 no skilled nurse visits were made. On 03/24/21 at 2:50 PM in an interview, Staff D was informed of the missing visits. She said she would look for them. On 03/24/21 at 4:07 PM the surveyor met with Staff D. Staff D could not present the additional skilled nurse visit notes. On 03/24/21 at 4:25 PM another meeting was held with Staff D. Staff D could not present the additional skilled nurse visit notes. On 03/24/21 at 4:45 PM an exit conference was held and no additional notes were presented. 2. The medical record review for Patient #1 was completed on 03/24/21. The medical record review revealed the patient's care began with the agency on 04/09/20. The plan of care for the certification period beginning 02/03/21 revealed the patient was diagnosed with hypertension, acute kidney failure, and altered mental status. The agency was directed to provide 38 to 42 hours of home health aide services. The medical record review revealed for the week of 02/07/21 32 hours of home health aide services were provided, for the week of 02/14/21 24 hours were provided, and for the week of 02/21/21 28 hours were provided. On 03/24/21 at 2:50 PM in an interview, Staff D was informed of the missing visits. She said she would look for them. On 03/24/21 at 4:07 PM the surveyor met with Staff D. Staff D could not present the additional home health aide visit notes. On 03/24/21 at 4:25 PM another meeting was held with Staff D. Staff D could not present the additional home health aide visit notes. On 03/24/21 at 4:45 PM an exit conference was held and no additional notes were presented.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to give drugs and treatments as ordered by the physician for two of seven patients reviewed (Patient #1 and #4). The census was 37 patients. Findings include: 1. The medical record review for Patient #1 was completed on 03/24/21. The medical record review revealed the patient's care began with the agency on 04/09/2020. The plan of care for the certification period beginning 02/03/21 revealed the patient was diagnosed with hypertension, acute kidney failure, and altered mental status. The agency was directed to provide skilled nurse visits twice a day to administer medications. Further review of the patient's record revealed the patient had medications ordered to be taken in the morning and one medication to be taken at bedtime, Aricept (used to treat confusion related to Alzheimer's disease). Medical record review revealed on 02/16/21 at 2:01 PM a skilled nurse visit was performed and the Aricept was given; on 02/22/21 at 4:00 PM a skilled nurse visit was performed and the medication was given; on 03/02/21 at 2:13 PM a skilled nurse visit was performed and the medication was given; on 03/03/21 at 3:43 PM a skilled nurse visit was performed and medication was given. On 03/24/21 at 4:40 PM in an interview, Staff A confirmed the medication was given in the afternoon and not at bedtime. 2. The medical record review for Patient #4 was completed on 03/24/21. The medical record review revealed the patient's care began with the agency on 12/19/18. The plan of care for the certification period beginning 02/06/21 revealed the patient was diagnosed with spina bifida and idiopathic scoliosis. The agency was directed to provide 12 skilled nurse visits a week to irrigate the bladder every morning and perform a bowel program in the afternoon Monday through Friday. A skilled nurse visit note dated 02/19/21 revealed a home visit was performed from 6:55 AM to 7:30 AM. The note stated there was 700 milliliters (ml) in the overnight bag and the bladder was flushed. A skilled nurse visit note dated 02/19/21 revealed another home visit was performed immediately thereafter from 7:30 AM to 8:06 AM. The review revealed a note stating "500ml of urine in overnight bag" and the bladder was flushed. Review of the notes for 02/19/21 did not reveal where a bowel program was performed. On 03/24/21 at 3:55 PM in an interview, Staff D confirmed the documentation and was unable to explain why the patient's bladder was flushed twice in one morning.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and medical record review, the facility failed to appropriately date and time all clinical record entries for one of seven sampled patients (Patient #4). The census was 37 patients. Findings include: The home health agency created skilled nurse visit entries via computer software. The medical record review for Patient #4 was completed on 03/24/21. Review of the plan of care for the certification period beginning 02/06/21 revealed the agency was directed to provide 12 skilled nurse visits a week to irrigate the bladder every morning and perform a bowel program in the afternoon Monday through Friday. A skilled nurse visit note dated 02/12/21 revealed a skilled nurse visit was provided from 6:38 AM to 7:13 AM and the patient's bladder was irrigated. Further review revealed another skilled nurse visit was performed immediately thereafter from 7:13 AM to 7:49 AM and the bowel program was performed. A skilled nurse visit note revealed a skilled nurse visit was provided on 02/26/21 from 6:38 AM to 7:18 AM and the patient's bladder was irrigated. A skilled nurse visit note revealed another skilled nurse visit was performed immediately thereafter from 7:19 AM to 8:00 AM and a bowel program was performed. On 03/24/21 at 3:42 PM in an interview, Staff D explained the nursing visits were not back to back because the bladder was irrigated in the morning and the bowels were managed in the afternoon. The documentation was reviewed with Staff D at that time. On 03/24/21 at 3:55 PM in an interview, Staff D again stated the visits were not done back to back and that the computer recorded times were in error. She was unable to explain why the errors occurred only on those days.