Every finding on record at Applesoft Homecare Svc LLC

A complaint investigation survey was conducted for complaint Intake 379868 on 11/072022. The certified and licensed home health services census was 25. Deficiencies were cited. Acronyms/Abbreviations: Adm-Administrator Alt Adm-Alternate Administrator Alt DON-Alternate Director of Nurses (Alternate Supervising Nurse) Admin Asst- Administrative Assistant Registered Nurse (RN) Licensed Vocational Nurse (LVN) Physical Therapist (PT) Occupational Therapist (OT) POC- Plan of Care SOC- Start of Care SN/SNV- Skilled Nursing/Visit MD-Medical Doctor

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, in one (Patient # 1) of two inactive records reviewed, the agency failed to assure communication with all physicians involved in the plan of care. The failure could lead to the primary care physician not being aware of patient health status changes. The failure could also cause patient harm and lack of quality care and service provision to the patient. FINDINGS INCLUDED: Record Review # 1: Review of Patient # 1’s clinical record revealed a POC for the treatment period 01/21/2022 to 03/21/2022, signed by the DON and dated 01/21/2022. The POC had a SOC date of 01/21/2022. The POC included a primary diagnosis of Pressure ulcer of sacral region, unstageable(unable to determine the depth/width/size of the pressure ulcer). The POC included orders for SN visits one time per week for one week, three times per week for eight weeks: PT and OT to evaluate and treat week of 01/26/2022. Further review of the POC revealed that it included orders for SN to perform wound care three times per week to left sacral wound and right sacral wound. The POC also included an order for PT/OT to teach patient/caregiver on proper patient safe handling using mobile lift and sling. Review of communication notes dated 02/05/2022 and 02/08/2022, signed by LVN A revealed that LVN A missed SN visits and did not perform wound care for the patient on those dates. The 02/05/2022 and 02/08/2022 communication notes had an attached note that read, “ Faxed to MD by [Admin Asst] 02/17/2022 (nine days after last missed visit). Review of SN visit note dated 02/09/2022 read in part: “…Patient is experiencing pain prior to wound care which is new…Patient was seen yesterday by visiting wound care doctor with no new orders sent to home health office or left in home. [Patient # 1’s family member] told be(sic) that they said to continue what we have been doing but to cover the areas with gauze & tape instead of optifoam. SN turned patient for wound care and there were gauze pads taped to the wound sites and along the patient’s spine. When SN removed the dressings, it was noted that the wounds had worsened and the wound edges were purple and edematous(swollen) where the gauze was applied to the patient’s spine the area is also purple/bruised in appearance. There is no phone number left in the patient’s home for the wound care doctor therefore I was unable to contact them regarding the wound status and new orders. SN contacted home health office to reported findings to [DON]…” There was no documentation in Patient # 1’s record that indicated Primary Care Physician, Identifier 200 was notified of the wound status change, on 02/09/2022. Review of SN visit note dated 01/26/2022 revealed that LVN A identified that Patient # 1’s caregiver stated that he “does not remember how to use [Hoyer lift, a mobile lift and sling to assist with patient mobility] and [Patient # 1] is afraid of it.” The SN note further revealed that a “request [was] sent to therapists to instruct [family member] on hoyer lift use.” Review of PT Referral A, that was dated 01/26/2022 and signed by the Adm read in part: “…PT to eval and treat… Decline reason: Sorry we cannot staff this...” Review of PT/OT Referral B, that was dated 01/28/2022 and signed by Admin Asst read in part: “…PT and OT to eval and treat…2 PT visits and 1 OT visit has been approved and we will request more with the evals…” Review of PT evaluation dated 02/01/2022 and signed by PT AA revealed that Patient # 1 declined PT services. The PT eval also read in part: “…[Caregiver] showed interest to learn how to use hoyer lift, because patient declined PT, OT will teach [caregiver] how to use hoyer in OT POC.” Review of OT evaluation dated 02/07/2022 and signed by OT AA revealed an order for OT visits one time per week for two weeks. The OT evaluation also read in part: “…Hoyer lift-not useable in current setting…” There was no documentation in Patient # 1’s record that indicated Primary Care Physician, Identifier 200 was notified of the delay, by agency SN and/or PT/OT, in teaching patient/caregiver on proper patient safe handling using mobile lift and sling/hoyer lift. There was no documentation in the Patient’s record that revealed the agency provided teaching to patient/caregiver on proper patient safe handling using mobile lift and sling/hoyer lift. Further review of Patient # 1’s record revealed a “patient communication” note that read in part: “…[Patient] has been referred to [Identifier 100] to assist with her wound.” The communication note was signed by Admin Asst and dated 01/24/2022. The record also included a patient communication note dated 02/03/2022 that read in part: “ Called [Identifier 100] to inquire about when a provider will be out to see the patient….[Identifier 100] stated that the patient will be seen on either …February 4th or…February 7th.” Continued review of Patient # 1’s record revealed that it contained a fax from Identifier 100 that was dated 02/11/2022. The fax contained wound care orders with an effective date of 02/08/2022 (date of Identifier 100’s visit to Patient # 1). There was no documentation in Patient # 1’s record that indicated Primary Care Physician, Identifier 200 was notified of the delay in visit from Identifier 100 for assistance with wound care. The referral was sent to Identifier 100 on 01/24/2022 and the visit was not completed until 02/08/2022. Continued review of Patient # 1’s record revealed a patient communication note that read in part: “…Agency notified by [LVN A] that the [patient] passed away this morning.” The communicate note was dated 02/10/2022 and signed by Admin Asst. The communication note had an attached note that stated the note was faxed by Admin Asst on 02/14/2022. Documentation in Patient # 1’s record indicated Primary Care Physician; Identifier 100 was not notified of Patient # 1’s death, on 02/10/2022, until 02/14/2022. During an interview with the Adm and DON, on 11/07/2022 at approximately 1:30 p.m., the surveyor discussed the above findings and asked why the agency failed to assure and document in the Patient record communication with the Patient # 1’s primary care physician. The DON replied, “I don’t remember if we were having to find [Patient # 1] a physician.” The surveyor also discussed how not communicating and documenting coordination of care with the Patient’s primary care physician could adversely affect the patient. The DON replied, “It could harm a patient.” The DON also stated that patient quality of care could also be affected. The Adm stated that it could cause re-hospitalization and frequent emergency room visits. Review of agency policy titled “TX.6 Plan of Care” dated 070121 read in part: “…Procedure…F. The physician is promptly alerted…to any relevant changes in the patient’s condition or needs that outcome are not being achieved and/or that the plan of care should be altered. There will be supporting documentation in the discipline’s progress notes or communication notes regarding contact with the physician…” Review of agency policy titled “TX.8 Coordination of Care” dated 010121 read in part: “Purpose [:] To ensure the effective exchange of information, reporting and coordination of patient care and services. Coordination of care will occur to ensure that patient needs are continually assessed, addressed in the plan of care, that care is delivered in a timely and effective manner…To ensure an interdisciplinary approach to coordination of care, treatment, and services… Policy…B…Agency will exchange information, report to and coordinate patient services among…All physicians/allowed practitioners involved in the POC…D. All coordination of care will be appropriately documented in the clinical record…”

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, in one (Patient # 1) of two inactive records reviewed, the agency failed to ensure that the patient and caregiver received ongoing education and training regarding care and services identified in the plan of care. The failure could place the patient at risk of injury and poor patient outcomes due to education and training not being provided, to the patient/caregiver, in the proper use of patient care equipment. FINDINGS INCLUDED: Record Review # 1: Review of Patient # 1’s clinical record revealed a POC for the treatment period 01/21/2022 to 03/21/2022, signed by the DON and dated 01/21/2022. The POC had a SOC date of 01/21/2022. The POC included a primary diagnosis of Pressure ulcer of sacral region, unstageable (unable to determine the depth/width/size of the pressure ulcer). The POC included orders for SN visits one time per week for one week, three times per week for eight weeks: PT and OT to evaluate and treat week of 01/26/2022. Further review of the POC revealed that it included orders for SN to perform wound care three times per week to left sacral wound and right sacral wound. The POC also included an order for PT/OT to teach patient/caregiver on proper patient safe handling using mobile lift and sling. Review of SN visit note dated 01/26/2022 revealed that LVN A identified that Patient # 1’s caregiver stated that he “does not remember how to use [Hoyer lift, a mobile lift and sling to assist with patient mobility] and [Patient # 1] is afraid of it.” The SN note further revealed that a “request [was] sent to therapists to instruct [family member] on hoyer lift use.” Review of PT Referral A, that was dated 01/26/2022 and signed by the Adm read in part: “…PT to eval and treat… Decline reason: Sorry we cannot staff this...” Review of PT/OT Referral B, that was dated 01/28/2022 and signed by Admin Asst read in part: “…PT and OT to eval and treat…2 PT visits and 1 OT visit has been approved and we will request more with the evals…” Review of PT evaluation dated 02/01/2022 and signed by PT AA revealed that Patient # 1 declined PT services. The PT eval also read in part: “…[Caregiver] showed interest to learn how to use hoyer lift, because patient declined PT, OT will teach [caregiver] how to use hoyer in OT POC.” Review of OT evaluation dated 02/07/2022 and signed by OT AA revealed an order for OT visits one time per week for two weeks. The OT evaluation also read in part: “…Hoyer lift-not useable in current setting…” Review of SN visit note dated 02/09/2022 read in part: “…Patient is experiencing pain prior to wound care which is new…Patient was seen yesterday by visiting wound care doctor with no new orders sent to home health office or left in home. [Patient # 1’s family member] told be(sic) that they said to continue what we have been doing but to cover the areas with gauze & tape instead of optifoam. SN turned patient for wound care and there were gauze pads taped to the wound sites and along the patient’s spine. When SN removed the dressings, it was noted that the wounds had worsened and the wound edges were purple and edematous (swollen) where the gauze was applied to the patient’s spine the area is also purple/bruised in appearance. There is no phone number left in the patient’s home for the wound care doctor therefore I was unable to contact them regarding the wound status and new orders. SN contacted home health office to reported findings to [DON]…” Continued review of Patient # 1’s record revealed a patient communication note that read in part: “…Agency notified by [LVN A] that the [patient] passed away this morning.” The communicate note was dated 02/10/2022 and signed by Admin Asst. The communication note had an attached note that stated the note was faxed by Admin Asst on 02/14/2022. There was no documentation in the Patients record, from SOC date of 01/21/2022 to date of death 02/10/2022, that revealed the agency and/or PT/OT had provided teaching to patient/caregiver on proper patient safe handling using mobile lift and sling/hoyer lift. During an interview with the Adm and DON, on 11/07/2022 at approximately 1:30 p.m., the surveyor discussed the above findings and asked who was responsible for follow-up with needed changes or further orders when care and services were delayed? The DON stated that he was responsible. The surveyor asked why there were no provision of and follow-up to patient and caregiver education/training for hoyer lift for Patient # 1? The DON stated that the agency goes “back and forward” with the case coordinators of the referral source/PT/OT. The DON also stated that the agency needs to coordinate better. The surveyor also discussed how this failure could adversely the patient? The DON stated that the failure could cause poor patient outcomes when the POC is not followed. Review of agency policy “PF.1 Agency Philosophy on Patient Education” dated 011318 read in part: “…Procedure…A. Education to improve health outcomes as appropriate to the care provided by the agency will be accomplished by…2.Ensuring that each patient, and his or her caregiver…receive ongoing education and training regarding the care and services identified in the plan of care that are specific to the patients’ health conditions and individual learning needs…” Review of Agency policy titled “TX.7 Implementing Care and Treatment” dated 010121 Read in part: “…To ensure patient care and treatment are provided as identified in the care planning process with implementation of best practices to improve the experience of care and outcomes of patients…” Review of agency policy titled “TX.8 Coordination of Care” dated 010121 read in part: “Purpose [:] To ensure the effective exchange of information, reporting and coordination of patient care and services. Coordination of care will occur to ensure that patient needs are continually assessed, addressed in the plan of care, that care is delivered in a timely and effective manner…To ensure an interdisciplinary approach to coordination of care, treatment, and services…”

Purpose of Visit: Recertification Survey Conducted entrance conference on 8/11/21 at 1:25 PM with agency administrator. Informed administrator that the purpose of the visit was to conduct a recertification survey. Provided Comment Card, "New Tool for Reporting Survey Inconsistencies," and "What to Expect" letter. Requested documents and provided opportunity to ask questions. Entrance: 8/11/2021 Census: L&C: 45 LHH: 24 Total: 69 Conducted exit conference on 8/20/2021 at 3:56 PM with administrator. Presented and discussed preliminary findings. "Provided How to Write an Acceptable Plan of Correction" letter and provided opportunity to ask questions.

Purpose of Visit: Recertification Survey Conducted entrance conference on 8/11/21 at 1:25 PM with agency administrator. Informed administrator that the purpose of the visit was to conduct a recertification survey. Provided Comment Card, "New Tool for Reporting Survey Inconsistencies," and "What to Expect" letter. Requested documents and provided opportunity to ask questions. Entrance: 8/11/2021 Census: L&C: 45 LHH: 24 Total: 69 Conducted exit conference on 8/20/2021 at 3:56 PM with administrator. Presented and discussed preliminary findings. "Provided How to Write an Acceptable Plan of Correction" letter and provided opportunity to ask questions.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure that annual bloodborne pathogens training as required by the Occupational Safety and Health Administration (OSHA) 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens was completed for 7 of 10 employees providing face-to-face patient care (Employees E, F, G, H, I, J, and K) for the past year (2020-2021). This failure could result in employees failing to prevent the spread of bloodborne pathogen, thus increasing the risk of harm to patient and employees. Findings: Review of agency policy titled, "In-services and Administrator Training" (dated 01/13/18) read in part: "Direct patient care staff is required to attend the following in-services, either internally or externally on hire, on an annual basis or when policies change ... Bloodborne Pathogens Program ..." Review of the personnel records found in part: 1. Employee E (RN) with a hire date of 6/24/19 had no BBP training for 2020/2021. 2. Employee F (LVN) with a hire date of 10/12/12 had no BBP training for 2020/2021. 3. Employee G (PT) with a hire date of 6/11/19 had no BBP training for 2020/2021. 4. Employee H (LVN) with a hire date of 10/12/19 had no BBP training for 2020/2021. 5. Employee I (LVN) had a hire date of 7/30/19 had no BBP training for 2020/2021. 6. Employee J (HHA) had a hire date of 1/26/15 had no BBP training for 2020/2021 7. Employee K (HHA) had a hire date of 1/1/08 had no BBP training for 2020/2021. In an interview on 8/20/2021 3:45 PM with agency administrator (Employee A), when asked if agency had conducted annual bloodborne pathogen training for 2020 and 2021 as required by OSHA, administrator (Employee A) said, "We haven't done that."