Every finding on record at Ancora Home Health & Hospice LLC

An unannounced Emergency Preparedness survey was conducted on 2/21/25 at Ancora Home Health and Hospice (Home Health). The agency was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers. State of Alaska Department of Health Division of Health Care Services Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, AK 99503

The following deficiencies were noted during an unannounced Federal Recertification survey conducted 2/13/25, 2/14/25, 2/18-21/25, and 2/24/25 at Ancora Home Health and Hospice (Home Health). One complaint was reviewed during the survey: AK #3743 was unsubstantiated due to lack of evidence. Sample size: 17 records Active Records: 12 records Closed Records: 5 records Home visits conducted: 7 home visits with 6 skilled nurse observations and 1 Physical Therapy observations: Skilled unduplicated Census for the past year: 2347 State of Alaska Department of Health Division of Health Care Services Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, AK 99503

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 record review and interview, the agency failed to ensure the plans of care were signed by the primary physician or nurse practitioner for 3 (# 5, #11, #13) of 17 records reviewed. This failed practice placed the home health patients at risk for less than optimal care. Findings: Record #5 Record review from 2/13-24/25 of Record #5, a closed record, revealed a start of care (SOC) date of 11/21/24 with a certification period of 11/21/24-1/19/25 and discharge on 12/11/24. The patient's diagnoses included Non-ST elevation myocardial infarction ( a type of heart attack) and acute respiratory failure with hypoxia (lungs can't exchange air gases and the body does not receive enough oxygen). The Home Health Certification and Plan of Care for the certification period of 11/21/24-1/19/25 was included in this record and had not been signed by the physician. During an interview on 2/21/25 at 2:41 PM, the Social Worker (SW) #1, when asked if the plan of care had been signed by the physician, stated that it had been sent to the physician and was not returned at this time. Record #11 Record review from 2/13-24/25 of Record #11, an active record, revealed a SOC date of 9/12/24 with a certification period of 1/10/25-3/10/25. The patient's diagnoses included Type 2 Diabetes Mellitus with hyperglycemia [high blood sugar] and Chronic Obstructive Pulmonary Disease. The Home Health Certification and Plan of Care for the certification period of 1/10/25 -3/10/25 was included in this record and had not been signed by the physician. During an interview on 2/21/25 at 11:00 AM, the Branch Administrator, when asked if the plan of care had been signed by the physician, stated it was possible the plan of care was not signed by the physician. Record #13 Record review from 2/13-24/25 of Record #13, an active record revealed a SOC date of 1/23/25 with a certification period of 1/23/25-3/23/25. The patient's diagnoses included Sepsis due to Escherichia Coli (a life-threatening condition that occurs when the body's immune system overreacts to a bacterial infection, leading to widespread inflammation and organ damage.)The Home Health Certification and Plan of Care for the certification period of 1/23/25-3/23/25 was included in this record and had not been signed by the physician. During an interview on 2/21/25 at 1:07 PM, SW #1, when asked if the plan of care had been signed by the physician, stated that the plan of care was not signed at this time. The agency's policy titled "Plan of Care - CMS #485 and Physician Orders," revised August 2020, revealed, "Skilled nursing and other home health services will be in accordance with a plan of care based on the patient's diagnosis and assessment of immediate and long range needs and resources. Each plan of care must be signed and dated by the physician...Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific outcomes and goals, which is established, periodically reviewed [every 60 days or more frequently when indicated by changes in the patient's condition] and signed by a Doctor of Medicine, osteopathy, or podiatry and Nurse Practitioners per State Practice Act within the scope of his or her state license, certification or registration..."

An Emergency Preparedness Survey was conducted by the State Survey Agency in accordance with 42 CFR 484.102 Provider #: 02-7008 Facility ID#: HHA-014 Visit dates: 2/7/22 - 2/15/22 Skilled Unduplicated Census past 12 months: 1553 Patients At this Emergency Preparedness survey, Ancora Home Health and Hospice was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers. State of Alaska Department of Health and Social Services Health Facilities Licensing and Certification 4601 Business Park Blvd.,Bldg K Anchorage, AK 99503

The following deficiencies were noted during an unannounced Federal Recertification Survey conducted 2/7/22 - 2/15/22 at Ancora Home Health and Hospice. Complaint # 62218 was unsubstantiated with no findings. 286 Active Patients 1553 Skilled Unduplicated Census Sample Size: 17 sampled patients, 0 non-sampled patients, and 5 closed records State of Alaska Department of Health and Social Services Health Facilities Licensing and Certification 4601 Business Park Blvd., Bldg K Anchorage, AK 99503

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 record review and interview, the agency failed to ensure the plans of care were signed by the primary physician for 1 of 12 active records reviewed (# 10). This failed practice placed the home health patients at risk for less than optimal care. Findings: Review on 2/11/21 of Record #10 evidenced a start of care of 11/13/21 with a certification period of 1/12/22 - 3/12/22. Diagnoses including pressure ulcer of left hip stage 4, Pressure ulcer of right hip, stage 4, and complete paraplegia. The Home Health Certification and Plan of Care for the certification period of 1/12/22 - 3/12/22 was included in this record and had not been signed by the physician. During an interview on 2/11/22 at 2 PM, the administrator stated that there was no signed plan of care in the record at this time when asked if the plan of care was signed by the physician. The administrator stated the plan of care was completed on 1/19/22 and sent to the physician on 1/19/22. Review of the policy "Plan of Care - CMS #485 and Physician Orders" revised August 2020 stated, "Each patient must receive the home health services that are written in an individualized plan of care … which is established, periodically reviewed … and signed by a doctor of medicine, osteopathy or podiatry and Nurse Practitioners per State Practice Act within the scope of his or her state license, certification or registration."

Disclosure of ownership and management info. CFR(s): 484.100(a) Standard: Disclosure of ownership and management information. The HHA must comply with the requirements of part 420 subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure notification was made to CMS and the state agency regarding location change of the agency and change in the administrator. Findings: Regarding address location and lack of notification to the state agency and CMS: On 2/7/22 at 9:10 AM, it was observed that the agency was located at 3831 E Blue Lupine Drive, Suite B, Wasilla AK 99654 and not at 2581 Palmer / Wasilla Highway Suite 7 Wasilla AK per state agency documentation. During an interview on 2/11/22 at 9:50 AM, the administrator and alternate administrator stated when asked about the new location for the agency that the move occurred on December 20, 2021. The move was from 2581 Palmer / Wasilla Highway Suite 7 Wasilla to 3831 E. Blue Lupine Drive, Wasilla AK. On 2/15/22 at 9:20 AM, after the attendees to the exit conference were asked if the 855 had been completed, the administrator stated the MAC had been notified via the online system 4 days ago. Regarding administrator change and lack of notification of administrator change to the State Agency: During an interview on 2/7/22 at 2:53 PM, the administrator stated her position as Administrator began on 11/22/21. During an interview on 2/11/22 at 10:00 AM, the administrator stated when asked if the state had been notified about the change of administrators, " I was told that was done [by the Governing Body.]" The administrator added, "This will be completed this afternoon." Review of a policy titled "Organization and Services Administration" revised August 2020 stated, "The Administrator will notify the state, CMS, and pertinent entities of address changes for all locations … The agency will notify the state, CMS and pertinent entities of a change in the administrator."