Every finding on record at American Homecare Management Corp.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 11/06/2024. 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 partial extended survey for Medicare recertification for the home health provider was completed on 11/06/2024. The provider had 218 current patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the provider failed to ensure the initial assessment was completed within 48 (forty-eight) hours of the referral in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect the immediate needs of all the provider’s patients. Findings included: Review of the provider’s policy titled, “03-05 Patient Assessments,” with the most recent annual review date of “08/2024”, showed in part, initial assessments must be completed on or before start of care and within 48 (forty-eight) hours from the date of referral or facility discharge (whichever is later) unless otherwise ordered by the physician or allowed practitioner. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 09/18/2024 with a primary diagnosis of radiculopathy, thoracic/lumbar region (the pinching of nerves at the root of the middle and lower back). Review of a faxed referral cover sheet to the home health provider showed: - It was dated 09/13/2024 from the referring physician; and - “Please call if can’t accept”. Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 09/16/2024 (three days (72 hours) following referral) showed: - Item M0104- Date of referral 09/16/2024; and - Item M0102- Date of physician-ordered SOC marked N/A, no specific SOC date. Further review of the clinical record failed to show a specific physician ordered start of care or any communication regarding the late start of care. During an interview on 11/06/2024 at 11:00 AM, clinical manager B stated that: - This was a new nurse; - He/she should have contacted the physician for a new verbal start of care date; and - He/she incorrectly completed the OASIS item M0102.

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 home health provider failed to ensure a complete and accurate medication list was maintained in, one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy titled, 03-41 “Medication Review and Documentation,” revision date October 2024, showed in part: - During each patient visit, the home health agency (provider) will review all medications the patient is taking - both prescription and over the counter (OTC) - to include all routes of administration; - Medication review will be performed by a clinical associate each visit to ensure medications are current, accurate and documented on the medication profile within the patient's medical record; - OTC drugs and herbal compounds - will also be included as part of the patient medication assessment and documented within the patient's medical record; - When conducting medication review, clinical associates must complete the following actions with the patient/caregiver and/or staff regardless of the patient's place of residence; * Examine and discuss with the patient/caregiver; * Medication bottles; * Prescriptions; * Current medication lists provided by the patient; and - Medication review includes all prescription medications, OTC medications and supplements/herbals administered by all routes. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 09/21/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (recent onset worsening of a disease or an increase in its symptoms) and hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney disease. Observation and interview on 11/05/2024 at 12:00 PM, during the patient's home visit, showed the following discrepancies: - The medication profile showed the patient took albuterol (opens airways to make breathing easier) sulfate HFA 90 micrograms (mcg) / actuation aerosol inhaler two puffs four times daily for shortness of air. The patient stated he/she used it as needed and hadn’t used since his/her flare up on 09/10/2024; and - The patient's medication bottles showed probiotic 10 billion cell capsule for GI (gastrointestinal) health. The patient stated he/she took one capsule two times daily and had been taking for about one month since he/she was dismissed from the hospital. The medication was not on the patient’s medication profile. Per interview conducted during the observation, LPN (licensed practical nurse)-C stated that he/she would notify the physician and get the discrepancies clarified. During an interview on 11/06/2024 starting at 10:30 AM, the administrator stated that he/she expected medications to be reviewed every visit and with every discipline to conduct a medication reconciliation.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to maintain professional standards according to their provider policy when wound measurements were not performed/documented weekly in the clinical record in two of two applicable records (Records/Patients #1 and #4). This deficient practice has the potential to affect all wound care patients served by the provider. RECORD/PATIENT #4: Review of the plan of care POC dated 09/18/2024 to 11/16/2024, showed in part: - Patient admitted to home health provider 09/18/2024; - Diagnoses included but not limited to type II diabetes mellitus with foot ulcer (open sore or wound), non-pressure chronic ulcer of left heel and midfoot with severity, and encounter for surgical aftercare following surgery on the circulatory system (surgical procedure that involves the heart, or the blood vessels that carry blood to and from the heart); and - SN to perform wound care to left medial big toe and change dressing every Monday, Wednesday and Friday. Review of the SN visit note report dated 09/18/2024 showed left (LT) - proximal (prox) (nearer to the center (trunk of the body) or to the point of attachment to the body) plantar (part of the foot contacting the ground), LT, diabetic ulcer surgical wound measured 7 x 4.5 x 0.3. Review of the SN visit note reports dated 09/23/2024, 09/25/2024, 09/27/2024, 09/30/2024 and 10/04/2024 failed to show documentation of wound measurements. Review of the SN visit note report dated 10/07/2024 showed LT – prox plantar, LT, diabetic ulcer surgical wound measured 4.3 x 4.4 x 2.8. During an interview on 11/06/2024 at 11:05 AM, the clinical manager A stated no wound measurements were done for the weeks of 09/22/2024 and 09/29/2024 and he/she would expect them to be done weekly. Findings included: Review of the provider’s policy titled "03-51 Wounds: Assessment/Care/Clinical Oversight," with the most recent annual review date of “08/2024” showed in part, at least once weekly the wound will be measured: length x width x depth (length by width by depth) in centimeters. RECORD/PATIENT #1: Review of the plan of care (POC) dated 08/22/2024 to 10/20/2024, showed in part: - Diagnoses included but not limited to: disruption of external operation (surgical wound) (also known as wound dehiscence or separation- when a surgical wound reopens) and cutaneous abscess of abdominal wall (localized infection in the fatty tissue just under the skin); and - SN (skilled nurse) to perform/teach wound care to abdominal surgical wound. Review of the SN visit note report dated 10/05/2024 showed mid suprapubic (area of the abdomen located below the navel and above the pubic bone) surgical wound measured 0.4 x 0.4 x 0.2. Review of the SN visit note report dated 10/14/2024 showed mid suprapubic (area of the abdomen located below the navel and above the pubic bone) surgical wound measured 0.2 x 0.2 x 0.3. Review of the SN visit note reports the week of 10/06/2024 to 10/12/2024 dated 10/07/2024, 10/09/2024 and 10/11/2024 failed to show documentation of wound measurements. During an interview on 11/06/2024 at 10:20 AM, the administrator stated wound measurements are done weekly and confirmed there were no wound measurements documented the week of 10/06/2024 to 10/12/2024.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 03/09/2022. During the survey it was determined Kindred At Home is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Kindred At Home was completed on 03/09/2022. The agency had 259 current patients.

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, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in one (Record/Patient #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 titled “Care Planning,” dated 06/2021 showed: - Each patient must receive an individualized written POC including any revisions or additions; - The individualized POC is comprised of the home health certification and POC form, and all subsequent orders received during the patient’s 60-day episode of care and must include: * All medications and treatments; * Safety measures to protect against injury; * Patient and caregiver education and training to facilitate timely discharge; * Patient-specific interventions and education; * Measurable outcomes and goals identified by the home health agency and the patient; * Additional items the home health agency, physician or allowed practitioner may choose to include; and - The case manager retains the overall responsibility for the care of the patient and determines the appropriateness of assignment of tasks. When assigning wound care to an licensed practical nurse (LPN), the registered nurse (RN) is responsible for reassessment visits every two weeks, verification of data collected and reported by the LPN, and evaluation of the effectiveness of the current care regimen to ensure progress toward goals. RECORD/PATIENT #4: Review of the hospital clinical encounter summary dated 01/06/2022 at 1:15 PM, showed the following: - Edema of both the left hands and legs, 1+ pitting edema (excess fluid builds up in the body and when pressure is applied to the swollen area, an indentation will remain; and grading the pitting edema is based on the depth and duration of the indentation); - Generalized erythema (superficial reddening of the skin, a result of injury or irritation) in gluteal folds (prominent fold on the back of the upper thigh that marks the upper limit of the thigh from the lower limit of the buttock) with skin tear overlying coccyx (small triangular bone at the base of the spinal column); and - Pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of buttock and wound care referral. Review of the comprehensive start of care assessment, dated 01/31/2022, showed, in part: - 2+ pitting edema to left lower extremity; - Last bowel movement was 01/21/2022, and the gastrointestinal assessment showed constipation; and - Patient has healed pressure ulcer on right buttocks and small-reddened areas on left buttock. Review of the patient's plan of care dated 01/31/2022 to 03/21/2022, showed, in part: - Diagnoses included, but not limited to, gastritis (stomach inflammation, irritation, or erosion of the lining of the stomach), type 2 diabetes mellitus without complications, cellulitis (common, potentially serious bacterial skin infection, the affected skin appears swollen and red and is typically painful and warm to touch), and constipation; - Ducosate sodium 100 milligrams (mg) daily for constipation; - Skilled nurse to evaluate and develop plan of care; - Assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications; - Skilled nurse to observe/assess integumentary system and cardiovascular status identify changes, and intervene to minimize complications; and - Changes in skin integrity will be identified promptly and interventions initiated to minimize risks. The plan of care failed to address the patient’s edema, reddened areas on left buttocks, and constipation. During an interview on 03/09/2022 at 10:55 AM, the clinical manager stated he/she would have expected the pitting edema, constipation and area on buttock addressed in the plan of care with individualized interventions.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the plan of care (POC) was revised/updated to address patient’s needs for one (Record/Patient #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 titled “Care Planning,” dated 06/2021 showed: - Each patient must receive an individualized written POC including any revisions or additions; - Plans of Care will be reviewed and revised as necessary to meet the changing needs of the patient in the most effective manner to achieve the desired outcomes; and - The case manager retains the overall responsibility for the care of the patient and determines the appropriateness of assignment of tasks. When assigning wound care to a licensed practical nurse (LPN), the registered nurse (RN) is responsible for reassessment visits every two weeks, verification of data collected and reported by the LPN, and evaluation of the effectiveness of the current care regimen to ensure progress toward goals. RECORD/PATIENT #4 Review of the patient's plan of care, dated 01/31/2022 to 03/21/2022, showed, in part: - The patient was admitted to home health services on 01/31/2022; - Diagnoses included, but not limited to, gastritis (stomach inflammation, irritation, or erosion of the lining of the stomach), type 2 diabetes mellitus without complications, cellulitis (common, potentially serious bacterial skin infection, the affected skin appears swollen and red and is typically painful and warm to touch), and constipation; - Docusate sodium (used to treat constipation) 100 milligrams (mg) daily for constipation; - Mupirocin (Bactroban- used to treat skin infections) 2 percent topical ointment three times a day for skin infection; - Skilled nurse to evaluate and develop plan of care; - Assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications; - Skilled nurse to observe/assess integumentary system and cardiovascular status identify changes, and intervene to minimize complications; and - Changes in skin integrity will be identified promptly and interventions initiated to minimize risks. Review of the occupational therapy (OT) evaluation note, dated 02/01/2022 at 2:41 PM showed: - Integumentary assessment showed a red area on buttocks (no further assessment); - Past medical history included pressure ulcer on buttocks; - Communicated with skilled nurse; and - The agency failed to update the plan of care to include the patient’s buttocks. Review of the skilled nurse (SN) visit note, dated 02/04/2022 at 11:42 AM showed: - 2+ pitting edema lower right extremity, 1+ upper right extremity and trace edema to upper and lower left extremity; - Patient had redness on coccyx and patient’s spouse putting “butt cream” on the reddened area; - The skilled nurse taught on shifting weight using small pillow or towel; and - The agency failed to update the POC to include edema, redness on coccyx and treatment, and education to reduce pressure to coccyx. Review of the SN visit note, dated 02/09/2022 at 9:27 AM showed: - Trace edema to upper right extremity, 1+ to lower right and left extremity; - Patient state docusate is not helping with constipation and SN to notify physician; - The patient encouraged to drink more water, avoid dehydration and promote good bowel management; - No skin issues noted; and - The agency failed to update the POC to include edema and constipation. Review of the physical therapy assistant (PTA) visit note, dated 02/14/2022 at 9:47 AM, showed patient had a fall yesterday (02/13/2022) resulting in two abrasions on left arm and the physician was notified. Care was coordinated with registered nurse. The agency failed to update the POC to include abrasion to the patient’s left arm. Review of the client occurrence report prepared by PTA, dated 02/14/2022 at 10:01 AM showed: - The patient fell yesterday (02/13/2022) in his/her bedroom and slid down the wall resulting in two abrasions on his/her left upper extremity; - One abrasion on elbow and another one just distally; - Both abrasions dressed upon the therapist arrival with a 4x4 and Coban (self-adherent wrap used to secure dressings) on his/her elbow and a Band-Aid on his/her distal abrasion; - Observed areas with no irritation or signs of infection noted and areas no longer bleeding with dry blood on 4x4 and Band-Aid, slight bruising around abrasions noted; - The physician notified; and - The agency failed to update the plan of care to include the two abrasions and treatment. Review of the SN visit note, dated 02/15/2022 at 9:47 AM, showed integumentary assessment showed “mottled” (skin has patchy and irregular colors) and poor turgor (skin’s elasticity) (there was no further assessment). There was no assessment of the patient’s abrasions to the left arm. The agency failed to update the POC to include abrasions to the left arm. Review of the physical therapist note, dated 03/02/2022 at 12:24 PM showed: - No open areas noted on buttocks; - The buttocks is very dark red and redness now covers both gluteal (buttocks) areas; - Appears worse than when patient last assessed- possible yeast infection; - The RN has been notified as they have been monitoring; - Left foot at base of toes has dried blood and drainage that has dried and RN notified (no further assessment); - Significant edema; and - The agency failed to update the POC to include the patient’s buttocks and edema. Review of the SN visit note, dated 03/03/2022 at 3:08 PM showed: - Patient had redness to bottom, which appears to look like “yeast”, and has been using Bactroban ointment on it but this has not healed; - New orders have been obtained and the rash to bottom was not addressed, requested again that patient be able to use over the counter or prescription medications for what appears to look like yeast to bottom, medical assistant to talk with physician and call back; - 2+ edema to lower left and lower right extremity and 1+ to upper right extremity; - Gastrointestinal assessment shows constipation and last bowel movement was 02/28/2022; and - The agency failed to update the POC to include rash to the patient’s buttocks, edema and constipation. Review of the client coordination note, dated 03/06/2022 showed factors contributing to lack of progress include possible underlying cardiac conditions causing fluid retention. The agency failed to update the POC to include edema. Review of the SN visit note, dated 03/08/2022 at 2:56 PM showed: - Integumentary assessment findings: Pale, poor turgor and other (there was no assessment of the patient’s buttocks); - Co-morbid condition with new symptoms identified: 3+ pitting edema to both lower legs; - Patient had 3+ edema in both legs and patient had some swelling in right hand; - Physician was notified and awaiting call back from the physician’s office; and - The agency failed to update the POC to include edema. During a telephone interview on 03/09/2022 at 11:57 AM, the patient’s caregiver stated that: - The patient’s red area on his/her buttocks was the beginning of a pressure ulcer because the patient sits a lot; - The wound care clinic saw the patient, there were changes and the area was not open; - The last week the agency offered more options for the patient’s rash on buttocks and maybe it was a fungus and he/she is applying Lotrimin (antifungal); - The agency addressed the constipation and the patient taking Miralax daily instead of docusate; - The scratch on his/her arm had healed; - The edema yesterday was the worst he/she had ever seen and he/she keeps the patient’s feet elevated; and - The nurse visited yesterday (03/08/2022) and noted the swelling and the nurse was to see about compression stockings. During an interview on 03/09/2022 at 10:55 AM, the clinical manager stated he/she would have expected the edema, constipation and area on buttock addressed in the plan of care with individualized interventions. There was no further information provided.