Every finding on record at Americare Homehealth Services

The Americare Homehealth Sevices is in compliance with 42 CFR Part 484.22 Emergency Preparedness requirements Condition of Participation of Home Health Agencies (HHAs).

An unannounced Recertification/Emergency Preparedness and change of practice location requested on a CMS855 was conducted by the Puerto Rico State Agency surveyor at Americare Homehealth Services, on September 12 through 13, 2023. (Event ID 61002-H1). As results of finding during the Recertification and COVID-19 vaccine survey resulted in a finding of substantial compliance with 42 CFR §484 the requirements for Home Health Agency (HHA) with the following standard-level deficiencies listed below: The facility submitted a CMS 855 on 01/01/2023 to relocate the facility from 110 Ave. Laura Pinero, Ceiba P.R. to Ave. De Diego 580, Second Floor SteB, San Juan P.R. The facility was sharing space with Cuidado Casero Hospice 40-1512, on the second floor and on the First Floor Cuidado Casero Guaynabo 40-7013. During the Survey process it was found that the facility does not have an Administrator appointed by the governing board and a clinical manager. The Clinical Supervisor of Americare Homehealth Services is the same Clinical Supervisor of Cuidado Casero Guaynabo. Americare Homehealth Service only has 2 Registered Nurses (the Clinical Supervisor and the Case Manager). The Facility shares the Nursing Services and Therapeutic Services with Cuidado Casero Guaynabo and the Social Worker Services with Cuidado Casero Hospice, depending on staff availability or patient needs. Survey Date: 09/12/2023 through 09/13/2023 Patient Census: 10 Home Visits: 3 Records Reviewed: 2 Close Record Review: 2

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 a re-certification survey, interviews, three Home Visits (H.V), two records review (R.R) and two closed records review (C.R.R), it was determined that the agency failed to supervise personnel for reviewing in every home visit the medications that the patients are taking for 1 out of 7 drug regimen records reviewed during home visit (H.V. #3). Findings include: 1. H. V. #3 is an 86-year-old female patient and according on Home Visit (H, V.) performed on 09/13/2023 at 10:05 AM. start of care (SOC) was on 08/12/2023. The primary diagnosis was Pressure Ulcer of Right Lower Back Stage II, secondary diagnosis of Parkinson's Disease, Hypertension, Urinary and Bowel Incontinence, Age related Osteoporosis and Unspecified Dementia. a. The patient was visited on 09/13/2023 at 10:05 AM. at the patient home to evaluate the ulcer local care accompanied by the Registered Nurse (RN) case management (employee #2) and is the first time that this nurse visits the patient. The nurse ended the ulcer local care and then interviewed the patient caregiver related to the daily medications. According of the Initial Comprehensive Assessment was performed by the visiting nurse (employee #3) on 8/12/2023 on the item #10 of the Plan of Care used to write all medications used per the patient and specified dose, frequency, route and identify if the medications is new or if changed provide evidence that the patient received Alprazolam 0.5 mgs tablet by oral route 3 times daily, Carbidopa 25 mgs - Levodopa 100 mgs tablet 1 tablet by oral route 3 times daily, Rasagiline 1 mg tablet by oral route every day, Memantine 5 mgs. tablet by oral route 2 times per day and Losartan 25 mgs tablet 1 tablet by oral route every day. During the home visit RN#2 asked the patient caregiver related to patient daily medications. She stated that the patient did not receive the medication ‘Rasagiline '' until three weeks ordered by the patient physician. No evidence on the patient record and plan of care related to this medication. The visiting nurse failed to perform the drug regimen review according to the drug regimen protocol. b. The medical record was reviewed on 9/13/2023 at 1:00 PM with the agency's nurse supervisor (employee #1). The period reviewed is from 8/12/2023 to 9/13/2023. The facility ‘' Drug regimen protocol '' for all personnel who visits patients established that the personnel is responsible of monitoring the medication therapy including high risk medications on each patient visit and established that the personnel perform the drug regimen review weekly or before if it necessary. The personnel have to assess all medications that the patient is taking, to educate patient and caregiver about doses, frequency, route, uses and interactions with other medications and food interactions.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on Recertification Survey, review of facility Governing Body Manual , it was determined that facility failed to ensure that an administrator be appointed by the governing body, be responsible for all day to day operation of the home health agency. Findings include: 1. On facility CMS855 form Application data submitted of the change in practice location report Section 6: Ownership interest & Managing Control Inform that the administrator was the employee #4 the Educational Director. The Emergency Preparedness Manual identifies in the personnel telephone number updated on 11/10/2022, the employee #5 as the administrator. 2. Home Visit #2 and Record review #2 during telephonic interview performed on 09/12/2023 at 3:18 p.m. and 3:50 p.m. that the information brochure provided during the admission process provides evidence that the administrator was employee #5. 3. The employee #4 stated during interview on 09/12/2023 at 8:30 a.m. that she was the Educational Director since January 2023, she was not the administrator. 4. Facility does not provide written evidence related to administrator appointment. 5. At the end of the recertification survey the surveyor does not clearly know who the facility administrator was due to the Board of Directors employe#5 during interview on 09/13/2023 stated that the administrator was employee #4.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on a recertification Survey, review of facility governing body manual and meeting report, it was determined that the facility failed to ensure that an administrator was appointed by the facility governing body. Findings include: 1. On the facility 855 form Application for the relocation on the data report Section 6: Ownership interest & Managing Control Inform that the administrator was the employee #4 the Educational Director. The Emergency Preparedness Manual identifies in the personnel telephone’s number updated on 11/10/2022, the employee #5 as the administrator. 2. Home Visit #2 and Record review #2 during telephonic interview performed on 09/12/2023 at 3:18 p.m. and 3:50 p.m. that the information brochure provided during the admission process provide evidence that the administrator was employee #5. 3. The employee #4 stated during interview on 09/12/2023 at 8:30 a.m. that she was the Educational Director since January 2023, she was not the administrator. 4. Facility does not provide written evidence related to administrator appointment. 5. At the end of the recertification survey the surveyor does not clearly know who was the facility administrator due to the Board of Directors employe#5 during interview on 09/13/2023 stating that the administrator was employee #4.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on an recertification survey, review of facility documentation related to Duties and functions and credential files and interview with facility Clinical Supervisor (employee #1), it was determined that the agency failed to ensure that a clinical manager is available during all operating hours. Findings include: During an interview on 09/12/2023 at 8:30 a.m. the Educational Director employee #4 stated that the Clinical Supervisor employee #1 is in charge of all operational management of the agency. The Clinical Supervisor employee #1 stated on 09/12/2023 at 08:45 a.m. that she was appointment in February 2023 as Clinical Supervisor of the Americare Homehealth Service (407019) and Cuidado Casero Guaynabo (407013) Supervisor service program. 1.During the review of the credential file of employee #1 on 09/12/2023 at 9:00 a.m. reveals that she was appointment as Clinical Supervisor and the duties and functions as Clinical Supervisor. 2. No evidence was provided in writing with the name and the position of the person in charge as clinical manager with full authority to decision making as requested in the Home Health agency regulation. 3. The organizational structure of the facility remains accordingly with a Home Health Agency (HHA) Survey Protocol-State Operations Manual (SOM) Appendix B that is not updated. 4. Accordingly with the facility organizational chart there is no clinical manager to be included in the facility administrative organizational structure. 5. Facility failed to ensure that a clinical manager is included in the facility administrative organizational structure, and it is available during all operating hours.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on a recertification Standard review of policies and procedures and interview with Clinical Supervisor (employee #1) on 09/12/2023 at 8:45 a.m., it was determined that facility failed to appoint a clinical manager to provide oversight of all patient care services and personnel as required by regulation. Findings include: During interview on 09/12/2023 at 08:45 a.m. the Clinical Supervisor (employee #1) stated she is the person in charge of all operational management. Accordingly with revisions of regulation, the facility must appoint a qualified person to provide oversight patient care services and personnel, make patient and personnel assignments, coordinate patient care, coordinate referrals, assure patient needs and assure the development, implementation and updated of the individualized plan of care. 1. During the review of the credential file of employee #1 on 09/12/2023 at 9:00 a.m. reveals that she was appointment as Clinical Supervisor and the duties and functions were as Clinical Supervisor. 2. No evidence was provided in writing with the name and the position of the person in charge as clinical manager with full authority to decision making as requested in the Home Health Agency regulation. 3. The organizational structure of the facility remains accordingly with a Home Health Agency (HHA) Survey Protocol-State Operations Manual (SOM) Appendix B not updated. 4. Accordingly with the facility organizational chart there is not a clinical manager to be included in facility administrative organizational structure. 5. Facility failed to ensure that a clinical manager is included in the facility administrative organizational structure, and it is available during all operating hours.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on recertification conducted from 09/12/2023 to 09/13/2023, three home visits (HV), two records reviewed (RR), two closed records reviewed (CRR), and interview with the clinical supervisor (employee #1), it was determined that the facility failed to ensure that the clinical record comprehensive assessment documents the wound measurements once a week according to the policy/procedure and filed to monitoring glucose level accordance to patient plan of care (485) for five (5) out of seven (7) records reviewed. (HV #1, #3, R.R #1 and C.R.R #2). 4. H.V. #3 86 year old female patient admitted on 08/12/2023 with diagnosis Pressure Ulcer of Right Lower Back Stage II, Parkinson's Disease, Essential Hypertension, Age - Related Osteoporosis without Current Pathological Fracture, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Bowel and Bladder Incontinence. The medical record was review on 08/13/2023 at 1:00 PM and according of the plan of care provide evidence that the patient was visit two times a week to provide ulcer local care. The frequency of visits on the plan of care ordered and established on the first period for nursing services 1 visit per 1 week , 2 visits per 8 weeks, 1 visit per 1 week and 3 visits as needed. a. The record provide evidence that the patient was visited two times a week however, no evidence of ulcer measure on weeks 9/4/23 to 9/8/23 and 9/11/23 to 9/15/23. The Clinical Supervisor (employee #1) regarding ulcer measures was taken by the nurse the first day of the week. b. According of the facility Policy HC-400-16 established all lesion, ulcer or wound was estimated by the nurse weekly. The professional nurse measure the ulcer the first day of the week. The facility failed to ensure that the clinical record comprehensive assessment documents the wound measurements once a week according to the policy and procedure. The facility failed to ensure that information related to blood glucose monitoring as part of plan of care implementation are documented on each patient home visit. 2. R.R. #1 case a 61-year-old female who was admitted on 08/18/2023 with a diagnosis of Diabetes Mellitus Type (DM II), Diabetic Ulcer Plantar area, High Blood Pressures (HBP), and Anemia. Medical record was reviewed on 09/13/2023 at 10:31 a.m. with the Clinical supervisor (employee #1). During the review it was identified that in the plan of care (Form 485), it was established that blood glucose monitoring on each home visit will be performed to ensure blood sugar levels are controlled and prevent complications related with diabetes. While reviewing the case it was identified that the Registered Nurse visit patient on a frequency of 2 Visit per week per 8-week patient relative perform blood glucose monitoring with Dextrostick every visit. However, no evidence was found related to patient glucose level during the visit performed on 08/25/2023, on 09/06/2023, and on 09/08/2023. Facility failed to assess patient blood sugar levels to ensure they are in a normal or near-normal range, to help prevent or delay the onset of diabetes-related complications. 3. C.R.R. #2 case a 63-year-old female who was admitted on 04/08/2023 with a diagnosis of Disruption of External Operation Wound, Left Hip Pressure Ulcer Stage II, Muscle Weakness, DM II, Chronic Kidney Disease (CKD), End stage renal disease (ESRD), Dialysis, Peripheral Vascular Disease. The medical record was reviewed on 09/13/2023 at 2:00 p.m. with the Clinical supervisor (employee #1). During the review it was identified that in the plan of care (Form 485), it was established that blood glucose monitoring on each home visit will be performed to ensure blood sugar levels are controlled and prevent complications related with diabetes. While reviewing the case it was identified that the Registered Nurse visit patient on a frequency of 2 Visit per week per 8-week patient relative perform blood glucose monitoring with Dextrostick every visit. However, no evidence was found related to patient glucose level during the visit performed on 04/21/2023, on 04/27/2023, and on 05/26/2023. Facility failed to assess patient blood sugar levels to ensure they are in a normal or near-normal range, to help prevent or delay the onset of diabetes-related complications. Findings include: 1.HV# 1 an 84-year-old male patient admitted to the facility on 08/08/2023 with diagnosis Disruption of External Operation and Displaced intraarticular Fracture of Right Calcaneus. The patient with history of Atrial Fibrillation, Hypertension, Type 2 diabetes mellitus, Hypothyroidism and Hyperlipidemia. On 9/13/2023 at 10:30 AM, the patient's initial visit on 08/08/2023, there was no evidence of the healing and measurements of the wound by the nursing staff when the clinical record was evaluated. The clinical supervisor was interviewed on 09/13/23 at 2:20 p.m. regarding wound measurements and visits frequencies. She stated that the registered nurse takes measurements of the wound during the initial visit and the visit is made twice a week. The surveyor requested the policy and procedure to the clinical supervisor.

The Americare Homehealth Sevices is in compliance with 42 CFR Part 484.22 Emergency Preparedness requirements Condition f of Participation or Home Health Agencies (HHAs).

An unannounced abbreviated COVID-19 Focused Survey for Acute and Continuing Care Providers/ Emergency Preparedness and a Recertification was conducted by the Puerto Rico State Agency surveyor at Americare Home Health Services Inc., on April 07 through 08, 2021. (Event ID WURD11). As results of finding during the COVID-19 and Recertification survey resulted in a finding of substantial compliance with 42 CFR §484 the requirements for Home Health Agency (HHA) with the following standard-level deficiencies listed below: Survey Date: 04/07/2021 through 04/08/2021 Patient Census: 33 Home Visits: 3 Records Reviewed: 2 Close Record Review: 2 PUI-0 COVID-19 Positive Cases -0 Staff PUI- 0 Staff Positive COVID-19- 0

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 a recertification survey performed on 04/07/2021 through 04/08/2021 from 8:200 AM till 3:00 PM, Seven medical records reviewed : (Three Home Visit (H.V), Two Records Reviewed (R.R) and Two Close Records Reviewed (C.R.R)), with the Quality Coordinator (employee #2), it was determined that the agency failed to ensure that the comprehensive assessment must be performed within 48 hour of patient's return home from a hospital admission for 1 out of 7 records reviewed. (R.R #5) Findings include: 1. R.R. #5 is a 96 year's old male who was admitted on 01/29/2021 with a diagnosis of Urinary Tract Infection and Unspecified Urethral Structure Male. During review of the patient's medical record with the Quality Coordinator (employee #2) on 04/07/2021 at 1:25 PM, it provides evidence that patient was transferred to the hospital on 02/27/2021, patient was discharge from the hospital on 03/04/2021. The Registered Nurse (RN) performed the Resumption of Care on 03/09/2021. No evidence was found related to justification to enter the assessment after 120 hour (five days) from patient's return home after the hospitalization.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on a recertification survey performed on 04/07/2021 through 04/08/2021, three (3) Home Visit (H.V.) with records reviewed and seven (7) Record Reviewed (R.R.) with Clinical Manager employee #1, it was determined that the facility failed to ensure that all Home Health Agency (HHA) services must be provided in accordance with current clinical practice guidelines for infection control and accepted hand washing professional standards of practice for 1 out of 3 home visits (H.V. #3). Findings include: 1. H.V. #3 is a 75 years old female patient was visit on 04/07/2021 at 1:45 PM at the patient home to evaluate the ulcer local care procedure accompanied by the RN employee #4 and the Clinical Manager employee #1. a. The RN employee #4 for two occasions wash hands with soap and water, first apply the soap then opens the tap, puts her hands wash drys and turn off the tap. b. When the nurse ended the heel ulcer local care, she took the tube of Hydrogel, did not discard the first portion and placed portion of Hydrogel on the strip and then applied Hydrogel with cotton swap to the right heel ulcer. c. The RN employee #4 after handling the used material bags and closing them, she handles the sterile materials bags that were on the table and closed them. The nurse did not wash her hands or used hand sanitizer then she documented. When finish she took the plastic bag of used material and discarded the bag outside of the patient home. However, the nurse did not wash her hands with soap and water and did not used hand sanitizer. d. The RN #4 failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases during the right heel ulcer care, according with the Center for Disease Control and Prevention ( CDC ).

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on a recertification survey performed on 04/07/2021 through 04/08/2021, three (3) Home Visit (H.V.) with records reviewed and seven (7) Record Reviewed (R.R.) with QAPI officer employee #2 and interview, it was determined that the facility failed to ensure that the clinical records contain correct clinical past and current findings for each home health patient related to complete documentation of implementation of plan of care for 2 out of 7 records reviewed (H.V. #1, and #3) Findings include: A mechanism to ensure that information related with blood glucose monitoring as part of plan of care implementation are documented on each patient home visit were not promoted, not followed accordingly with the following findings: 1. H. V. #1 case a 62 years old female who was admitted on 11/20/2020 with a diagnosis of Left Lower Extremity Infected Amputation Stump and Type 2 Diabetes. Medical record was reviewed on 04/08/2021 at 10:50 AM, with the QAPI officer (employee #2). During the review it was identified that in the plan of care (Form 485) it was established that blood glucose monitoring on each home visit will be perform in order to ensure blood sugar levels are controlled and prevent complications of related with diabetes. While reviewing the case it was identified that patient relative perform blood glucose monitoring with Dextrostick every day. However, during home visit performed by nursing personnel on 04/02/2021 and 04/05/2021 blood glucose levels were not documented as part of patient assessment. Facility failed to assess patient blood sugar levels to ensure keep they are in a normal or near-normal range, to help prevent or delay the onset of diabetes-related complications. 2. H.V. #3 is a 75 years old female patient and according to record review performed on 04/08/2021 at 10:00 AM with the Clinical Manager (employee #1); the start of care (SOC) was on 03/29/2021. According to the physician order on 03/10/2021 the patient was referred to home care to received nursing services and physical therapy because the patient has a Left Stump partially open and Right Heel Ulcer. The patient initial assessment was performed by the nurse (employee #4) on 03/29/2021 and she established nursing services with a frequency of 3 visit for 9 weeks and physical therapy 1 visit per 1 then 2 visits per week for 7 weeks and 1 visit per 1week. Based on the initial assessment the patient is alert and oriented. Partially dependent on activities of daily living and needs assistance for bathing. a. The register nurse performed the initial assessment on 03/29/2021 and no evidence of Right Heel Ulcer and Left Stump measure.