Every finding on record at Angels Home Healthcare Services, Inc.

Recertification Survey conducted on 06/14/24. Standard level deficiencies cited. Abbreviations OASIS = Outcome and Assessment Information Set. Pt / Pts = Patient / Patients POC / PsOC = Plan of Care / Plans of Care BP = Blood Pressure SN = Skilled Nurse PT = Physical Therapy wk = week

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a review of the Agency's OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency's OASIS submission report was reviewed on 06/11/24. The report contained information that out of the Agency's 60 OASIS initial assessment reports, 13.33% were submitted beyond the required time frame of 30 days. 2. During an interview with the Director of Nursing on 6/13/24 at 10:30am. The Director of Nursing stated that Agency staff is not completing documentation on time causing the late submission. The Director of Nursing confirmed the Agency's late OASIS submission.

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 review of clinical records and staff interview, it was determined that in 2 of 7 (Pts. # 3 and 4) clinical records, the Agency failed to ensure the Plan of Care contained patient-specific interventions related/indicated for a pertinent Diagnosis. Findings include: 1. Pt. #3 was admitted to Home Health Services on 02/29/24 with Diagnosis Pressure Ulcer of Right Heel, Stage 4. The clinical record was reviewed on 06/12/24. The POC effective 04/28/24 to 06/27/24, included orders for discipline and treatment: “Notify Physician…. Blood sugar, Fasting….Blood Sugar, Random…” The POC included a blood sugar assessment intervention that was not indicated for Pt.#3’s diagnosis. During a home visit with Employee #3 (visiting RN) on 06/12/24 at 11:30 AM, Pt. #3 and family stated and confirmed that Pt. does not have a history or current diagnosis of Diabetes/Hyperglycemia. 2. Pt. #4 was admitted to Home Health Services on 03/16/24 with Diagnosis of Unspecified Fracture of Right Femur, subsequent encounter for closed fracture with routine healing. The clinical record was reviewed on 06/11/24. The PsOC effective 03/16/24 to 05/14/24 and 05/15/24 to 07/13/24, included orders for discipline and treatment: “Notify Physician…. Blood Sugar, Fasting….Blood Sugar, Random…” The POC included a blood sugar assessment intervention that was not indicated for Pt. #4’s diagnosis. 3. During an interview with the Director of Nursing on 06/13/24 at 11:00 AM, the Director of Nursing confirmed the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview it was determined the Agency failed to ensure staff provided services ordered by the physician in the plan of care. This was found in 5 of 7 (Pts # 7, 2, 3, 4, and 6) clinical records reviewed. 2. Pt. # 2 was admitted to Home Health Services on 02/19/24 with Diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The clinical record was reviewed on 06/12/24. The signed POC for certification period of 02/19/24 to 04/18/24, required to notify Physician of vital sign parameters out of range: “…. Diastolic BP: …. Less Than ( There was no documentation that Physician was notified of Diastolic BP of falling outside parameters as ordered in the POC. 3. Pt. #3 was admitted to Home Health Services on 02/29/24 with Diagnosis Pressure Ulcer of Right Heel, Stage 4. The clinical record was reviewed on 06/12/24. The POC for certification period of 04/28/24 to 06/27/24, required to notify Physician of vital sign parameters out of range: “…. Diastolic BP….Less Than( The SN visit dated 05/29/24, documented a diastolic BP of “52.” There was no documentation that Physician was notified of Diastolic BP of falling outside parameters as ordered in the POC. 4. Pt. #4 was admitted to Home Health Services on 03/16/2024 with Diagnosis of Unspecified Fracture of Right Femur, Subsequent for Closed Fracture. The clinical record was reviewed on 06/11/2024. The POC for certification period of 03/16/24 to 05/14/24, required SN frequency of 1 time a week for 9 weeks. The clinical record lack an SN visit for the week of 05/05/24 to 05/11/24. There was no modification in Physician orders or a communication indicating why no visits were done as ordered in the POC. 5. Pt. #6 was admitted to Home Health Services on 01/13/24 with Diagnosis of Lymphedema. The clinical record was reviewed on 06/11/24. The signed PT POC for certification period of 03/13/24 to 05/11/24, required PT frequency of 2 wk 6, 1 wk 1. The PT documented visits 1 time a week for on the following dates 03/16/24 (PT evaluation, week 1), 03/21/24 (week 2) and 03/26/24 (week 3). There was no modification or communication as to why PT visits were not done 2 times a week as ordered in the POC. 6. During interviews with Director of Nursing on 06/13/24 at 10:00 AM to 12:30 PM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. # 7 was admitted to Home Health Services on 01/11/24 with Diagnosis of Unspecified dementia, unspecified severity, with agitation. The clinical record was reviewed on 06/12/24. The clinical record contained a POC for certification period 03/11/24 to 05/09/24 that required PT to evaluate status and Aide services 2 times a week for 9 weeks. The record lacked PT evaluation and Aide services for certification period of 03/11/24.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey (FIC) was completed on 6/3/21. Kelly Home Health Care, Inc. was in compliance with the requirements for infection control for Covid 19. Abbreviations: & = and x = times wk = week # = number AM = morning POC = Plan of care SOC = Start of care SN = Skilled Nurse PsOC = Plans of Care N/A = Not Applicable RN = Registered Nurse PM = afternoon/evening HHA = Home Health Aide Pt./ Pts. = Patient/Patients DON = Director of Nursing OASIS = Outcome and Assessment Information Set

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: . A. Based on review of clinical records, policy, and staff interview, it was determined the Agency failed to provide the comprehensive assessment for the recertification period. This was found in 1 of 7 (Pt. #5) clinical records reviewed. Findings included: 1. Pt. #5. SOC 2/23/21. Primary Diagnosis: Hypertension. The clinical record was reviewed on 6/2/21 at 3:00 PM. The record included the SOC comprehensive assessment dated 2/23/21. As of 6/3/21, the record lacked completed comprehensive assessment for recertification period of 4/24/21 to 6/22/21. Pt. #5 is currently receiving services. 2. The Agency policy without title was reviewed on 6/3/21 at 3:00 PM. The policy documents: "It is the policy of (Agency) that comprehensive assessment is updated and revised (including the administration of the OASIS) as frequently as the patient's condition ...." "A comprehensive assessment is conducted by a qualified clinician to identify the patient's current health status and continued needs for home health services. A comprehensive assessment is updated and reviewed no less frequently than: The last (5) days of every 60 days beginning the start of care date unless there is a: Beneficiary elected transfer. Significant change in condition or Discharge and return to the same AGENCY during the 60-day episode" "The patient plan of care is updated when the comprehensive assessment is revised." 3. During an interview with the DON on 6/3/21 at 1:30 PM, the DON confirmed the comprehensive assessment was not done.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: . A. Based on clinical record review, Agency policy review and staff interview, it was determined the Agency failed to conduct and document comprehensive assessments that reflects an accurate picture of current Pt. status. This was found in 4 of 7 (Pts. #3, 4, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #3. SOC 2/22/21. Principal Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 6/1/21 at 3:00 PM. The clinical record included an initial comprehensive assessment dated 2/22/21 which included documentation: "M1870: ...Able to take in nutrients orally and receives supplemental nutrients through nasogastric tube or gastrostomy." The SN notes dated 2/26/21, 3/3/21, 3/10/21 did not include documentation indicating the Pt. had a feeding tube. During an interview with the DON on 6/3/21 at 9:30 AM, the DON stated that Pt. #3 never had a feeding tube. The comprehensive assessment dated 4/22/21 also lacked documentation of assessments for integumentary, gastrointestinal, and neurologic systems. 2. Pt. #4. SOC 4/20/21. Principal Diagnosis: Essential (Primary)Hypertension. The clinical record was reviewed on 6/2/21 at 5:00 PM. The record included an initial comprehensive assessment dated 4/20/21. The comprehensive assessment lacked documentation of an integumentary system assessment. 3. Pt. #6. SOC 3/13/20. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 6/2/21 at 4:00 PM. The record included a comprehensive assessment dated 5/8/20 which included documentation: "M1322...Current Number of Stage 1 Pressure Injuries ...2 ..." The SN notes for the entire episode of 5/12/20 to 7/10/20 did not include documentation indicating the Pt. had pressure ulcers. During an interview with the DON on 6/3/21 at 10:00 AM, the DON stated that Pt. #6 did not have a pressure ulcer. The same comprehensive assessment also lacked documentation of the gastrointestinal and nutritional systems assessments. 4. Pt. #7. SOC 5/25/17. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 6/2/21 at 12:30 PM. The record included a comprehensive assessment dated 3/22/21 which included documentation: "M1000 - N/A - Patient was not discharged form an inpatient facility." During an interview with the DON on 6/3/21 at 10:30 AM, the DON stated that Pt.#7 was admitted to an inpatient facility due to a kidney transplant, and thus a Resumption of Care assessment was completed. The same assessment lacked documentation indicating Pt. received a kidney transplant. 5. The untitled Agency policy which was reviewed on 6/3/21 at 2:00 PM requires: "The comprehensive assessment must accurately reflect the patient's status..." 6. During an interview with the DON on 6/3/21 from 9:30 AM to 10:30 AM, the above findings were confirmed.

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: . A. Based on review of clinical records, policy, and staff interview, it was determined the Agency failed to provide the plan of care for the recertification period. This was found in 1 of 7 (Pt. #5) clinical records reviewed. Findings included: 1. Pt. #5. SOC 2/23/21. Primary Diagnoses: Hypertension. The clinical record was reviewed on 6/2/21 at 3:00 PM. The record included the SOC comprehensive assessment dated 2/23/21. As of 6/3/21, the record lacked completed plan of care for recertification period of 4/24/21 to 6/22/21. Pt. #5 is currently receiving services. 2. The Agency policy without title was reviewed on 6/3/21 at 3:00 PM. The policy documents: "It is the policy of (Agency) that comprehensive assessment are updated and revised (including the administration of the OASIS) as frequently as the patient's condition ...." "A comprehensive assessment is conducted by a qualified clinician to identify the patient's current health status and continued needs for home health services. A comprehensive assessment is updated and reviewed no less frequently than: The last (5) days of every 60 days beginning the start of care date unless there is a: Beneficiary elected transfer. Significant change in condition or Discharge and return to the same AGENCY during the 60-day episode" "The patient plan of care is updated when the comprehensive assessment is revised." 3. During an interview with the DON on 6/3/21 at 1:30 PM, the DON confirmed the recertification OASIS has not been submitted by RN, therefore there is no updated plan of care.

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: . A. Based on observation and interviews during a home visit, clinical record review and staff interviews, it was determined that the Agency failed to ensure Plans of Care included all the requirements. This was found in 1 of 7 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 2/22/21. Principal Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. A home visit was conducted on 6/2/21 at 10:00 AM. Pt. #3 had oxygen at home and stated, "I use oxygen as needed..when I am short of breath." The clinical record was reviewed on 6/1/21 at 3:00 PM. The record included a POC for the period of 4/23/21 to 6/21/21. The POC lacked documentation of the rate/duration of administration and the delivery method of oxygen. 2. During an interview with the DON on 6/3/21 at 10:35 AM, the above findings were confirmed.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the HHA provided services as directed on the HHA Care Plan and as ordered by the physician. This was found in 1 of 1 (Pt. #7) clinical records reviewed, wherein the Pt. received HHA services. Findings include: 1. Pt. #7. SOC 5/25/17. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 6/2/21 at 12:30 PM. The record includes a POC for the period of 3/5/21 to 5/3/21 which requires: "HHA Frequency: 1 week 9." The clinical records reviewed showed documentation that Pt. received HHA services as follows: 2 times per week for the weeks of 2/28/21 to 3/6/21 and 3/7/21 to 3/13/21; 4 times for the week 3/21/21 to 3/27/21; 3 times for the week of 3/28/21 to 4/3/21; 2 times per week from 4/4/21 through 5/10/21. The HHA services provided was not in accordance with the HHA frequency as ordered by the physician. The same record contained the "HHA Care Plan" completed by the RN and dated 3/1/21. The Plan required the HHA to provide the following personal care every visit: "Nail Care." The following HHA notes dated: 3/3/21, 3/8/21, 3/10/21, 3/25/21, 3/27/21, 3/31/21, 4/21/21, 4/7/21, 4/12/21, 4/14/21, 4/21/21, 4/26/21, 4/28/21, 5/4/21 and 5/5/21 lacked documentation the HHA provided nail care during those visits. The clinical record lacked documentation of change of condition to warrant the HHA frequency change. 2. During an interview with the Director of Nursing on 6/3/21 at 10:00 AM, the above findings were confirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 3/13/20. Principal Diagnosis: Essential (Primary) Hypertension. The clinical records were reviewed on 6/2/21 at 4:00 PM. Discharge summery noted, dated 7/21/20. The clinical record lacked documentation the Agency sent a copy of the Discharge Summary to the Physician. Pt. #6 was discharged from the Agency on 7/21/20. 2. Pt. #7. SOC 5/25/17. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 6/2/21 at 12:30 PM. Discharge summary noted, dated 5/11/21. The clinical record lacked documentation the Agency sent a copy of the Discharge Summary to the Physician. Pt. #7 was discharged on 5/11/21. 3. The untitled Agency policy was reviewed on 6/3/21 at 2:00 PM. The policy requires: "A completed discharge summary is sent to the primary care practitioner or other healthcare professional who will be responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient's discharge." 4. During an interview was conducted with the Director of Nursing on 6/3/21 at 10:30 AM, the above findings were confirmed.