Every finding on record at Angels 2 You LLC

An Entrance Conference was conducted on 04/26/2022 with the Administrator/Supervising Nurse at 9:35 AM. The Agency representative was informed that the purpose of the survey was a Recertification Survey. The Agency census was: L&CHHS - 9 LHHS - 0 An Exit Conference was conducted on 04/28/2022 with the Administrator/Supervising Nurse and the Data Entry Clerk at 2:00 PM. The preliminary findings of the survey were discussed. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. Acronym/Abbreviations: POC – Plan of Care L&CHHS – Licensed and Certified Home Health Services LHHS – Licensed Home Health Services

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient's plan of care was reviewed by the patient's physician no less than once every 60 days, beginning with the start of care date for 4 of 7 patients (Patients #1, #3, #4 and #5) for which records were reviewed. This failure has the potential to cause harm to agency patients in that the physician may not be aware of changes in the patient's condition or the need for additional care and services. Findings Included: Review of the clinical record for Patient #1 revealed a start of care date of 11/03/2021. Review of the record revealed the plan of care for the certification period of 01/02/2022 to 03/02/2022. Further review of the POC revealed no documentation that the Physician A approved or signed the POC. Review of the clinical record for Patient #3 revealed a start of care date of 05/25/2020. Review of the record revealed the plan of care for the certification period of 01/15/2022 to 03/15/2022. Further review of the POC revealed no documentation that the Physician B approved or signed the POC. Review of the clinical record for Patient #4 revealed a start of care date of 01/15/2018. Review of the record revealed the plan of care for the certification period of 12/25/2021 to 02/22/2022. Further review of the POC revealed no documentation that the Physician B approved or signed the POC. Review of the clinical record for Patient #5 revealed a start of care date of 11/13/2015. Review of the record revealed the plan of care for the certification period of 12/11/2021 to 02/08/2022. Further review of the POC revealed no documentation that the Physician B approved or signed the POC. During an interview on 04/27/2022 with the Administrator/Supervising Nurse and the Data Entry Clerk at 2:45 PM, the surveyor reviewed the findings regarding the lack of physician signatures on the POC’s for Patients #1, #3, #4, and #5. The Administrator/Supervising Nurse stated that the physicians are taking a long time to return signed orders due to the pandemic. The Administrator/Supervising Nurse stated the POCs for Patients #1, #3, #4 and #5 had been sent to Physicians A and B for signature. The Data Entry Clerk stated that he had gone to the office of Physician A the morning of 04/27/2022 but the POC for Patient #1 was not ready with signature. The Administrator/Supervising Nurse stated that the office of Physician B had been contacted to retrieve the signed POC’s for Patients #3, #4 and #5 and she was told Physician B was not available to sign the POC’s. Review of the Agency’s policy and procedure manual revealed a policy entitled “Physician’s Orders,” dated 01/01/2012, which read in part, “5. Skilled care provided to a client is based on the plan of treatment signed within 45 days of the start of care or recertification date.”