Every finding on record at Aspen Home Health Medical & Rehabilitation Services, Inc.

Recertification survey completed. Standard Level deficiencies cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review, home visit observation and Staff interviews, it was determined that the Agency failed to ensure that Staff provided care as ordered by physician. This was found in 3 of 7 (Pts. #2, 3 and 4) clinical records reviewed. Findings include: 1. Patient #2 was admitted to Home Health Services on 10/30/23 with Diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 01/03/24. The signed Plan of Care orders effective 10/30/23 included a Physical Therapy (PT) frequency of 2 times a week for 5 weeks and 1 time a week for 4 weeks. The clinical record contained a PT note dated 11/20/23 (week 4). The record lacked documentation of another PT visit or communication as to why PT visits did not occur as ordered. The same Plan of Care orders required a Skilled Nurse (SN) to assess oxygen saturation on room air each visit. The SN note dated 12/21/23 lacked an Oxygen saturation assessment as ordered. 2. Patient #3 was admitted to Home Health Services on 05/16/23 with Diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 01/03/24. The signed Plan of Care orders effective 11/12/23 required a SN to perform finger stick for fasting blood sugar/random blood sugar during visit if it has not been done, or if patient reports signs and symptoms of hypo/hyperglycemia. The following SN visit notes dated 11/13/23, 11/21/23, 11/28/23, 12/12/23, 12/18/23 and 12/29/23 lacked Blood sugar assessments as ordered. A home visit was conducted with Patient #3 and Employee #3 (SN) on 01/03/24 at 3:15 PM. It was observed that the blood sugar assessment was not done as ordered. Employee #3 stated that Patient #3 refuses to check blood sugar himself or by the nurse and it should be documented in the record. There were no communication notes or modification of orders noted in the clinical record. The same Plan of care orders required SN to assess oxygen saturation on room air each visit. The SN note dated 12/29/23 lacked an oxygen saturation assessment as ordered. 3. Patient #4 was admitted to Home Health Services on 05/26/23 with Diagnosis of Trigger Finger, Left ring finger. The clinical record was reviewed on 01/03/24. The signed Plan of Care orders effective 09/23/23 and 11/22/23 required Skilled Nurse (SN) to assess oxygen saturation on room air each visit. The SN notes dated 11/10/23 and 12/22/23 lacked an Oxygen saturation assessment as ordered. 4. During an interview with the Administrator and Director of Nursing on 01/04/24 at 1:30 PM, the Administrative staff confirmed the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish a policy and plan, relative to the use of volunteers during an emergency. This has potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan last updated 1/28/21 was reviewed on 2/22/21 at 2:00 PM and 2/23/21 at 9:35 AM. The Plan lacked a policy and documentation relative to the use of volunteers. 2. During interviews with the Administrator and Quality Assurance Nurse on 2/22/21 at 2:00 PM and 2/23/21 with the Administrator at 9:45 AM, the Administrator and the Quality Assurance Nurse confirmed the Agency failed to incorporate volunteers into the Agency's Emergency Preparedness Plan.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan last updated 1/28/21 was reviewed on 2/22/21 at 2:00 PM and 2/23/21 at 9:35 AM. The communication plan consisted of an "Emergency Telephone Tree" and the "Actual Disaster Plan". The telephone tree and Disaster Plan lacked the names and contact information of the patients' physicians. 2. During an interview with the Administrator and the Quality Assurance Nurse on 2/22/21 at 2:00 PM and 2/23/21 at 9:45 AM with the Administrator, both the Administrator and the Quality Assurance Nurse confirmed the Agency failed to include the patients' physicians in the Agency's Emergency Preparedness communication plan.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 2/25/21. Standard level deficiencies written. Abbreviations: wk = week # = number % = percent pt's = patient's E = Employee AM = morning bilat = bilateral PRN = as needed BID = twice a day SN = Skilled Nurse POC = Plan of care SOC = Start of care tab(s) = tablet, tablets PsOC = Plans of Care MG / mg = milligrams RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients DON = Director of Nursing PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant mcg/act = micrograms per actuation COVID-19 = Coronavirus Disease 2019

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. are screened for COVID-19, prior to providing Pt. care and services. This was found in 5 of 7 (Pts. #3, 5, 6, 1 and 4) clinical records reviewed. Findings include: 1. Pt. #3. SOC 2/22/20. Diagnoses: Bilateral Primary Osteoarthritits of Knee and Lumboscaral Region Spondylosis without Myelopathy or Radiculopathy. The clinical record was reviewed on 2/24/21 at 11:00 AM. The record contained weekly Home Health Aide visit notes from 12/23/20 to 2/11/21, indicating the Home Health Aide provided service. The record lacked documentation the Home Health Aide screened the Pt./caregiver for COVID-19 symptoms, prior to the visits indicated above. The PTA provided service on 12/21/20. The record lacked documentation the PTA screened the Pt./caregiver for COVID-19 symptoms, prior to the visit on 12/21/20. 2. Pt. #5. SOC 2/6/21. Diagnoses: Acute Cystitis without Hematuria and Personal History of COVID-19. The clinical record was reviewed on 2/23/21 at 9:30 AM. The record contained documentation the SN provided service 1 to 2 times a week from 2/6/21 to 2/15/21, indicating the SN provided service. The record lacked documentation the SN screened the Pt./caregiver for COVID-19 symptoms, prior to the visits indicated above. The PT provided service on 2/11/20 and 2/15/20. The record lacked documentation the PT screened the Pt./caregiver for COVID-19 symptoms, prior to the visits indicated above. 3. Pt. #6. SOC 4/28/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 2/23/21 at 1:30 PM. The record contained PT visit notes for 2 times a week from 8/26/20 to 9/16/20, indicating the PT provided service. The record lacked documentation the PT screened the Pt./caregiver for COVID-19 symptoms, prior to the visits indicated above. 4. Pt. #1. SOC 9/28/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 2/23/21 at 10:00 AM. The record contained PT visit notes dated 1/27/21, 2/8/21, and 2/15/21, indicating Pt. #1 was provided service. The record lacked documentation the PT screened Pt. #2 for signs and symptoms of COVID-19, prior to the visits indicated above. 5. Pt. #4 SOC 5/20/19. Primary Diagnosis: Neuromuscular Dysfunction of Bladder, Unspecified. The clinical record was reviewed on 2/23/21 at 11:20 AM. The record contained a SN visit note dated 1/27/21, indicating Pt. #4 was provided service. The record lacked documentation the SN screened Pt. #4 for signs and symptoms of COVID-19, prior to this visit. 6. During the entrance interview with the Administrator and DON on 2/22/21 at 10:50 AM, the DON stated staff are required: "Call (Pt./caregiver) before the visit, ask there temperature and do they have any COVID symptoms, been around anyone with COVID. The staff document this information in the narrative of the visit form." 7. During interviews with the Administrator and the Quality Assurance Nurse on 2/23/21 at 2:55 PM, and with the Administrator and the DON on 2/25/21 at 11:30 AM, the Administrator confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on staff interviews, clinical record review and review of the of the Agency's Infection Control binder, it was determined the Agency failed to implement its COVID-19 infection control surveillance for the staff. This has the potential to affect all staff and Pts. within the Agency. Findings include: 1. During the entrance interview with the Administrator on 2/22/21 at 10:30 AM, the Administrator stated that since March 2020, the Agency had one employee (E#1) that tested positive or had known exposure to COVID-19. 2. During an interview with the Administrator and the Quality Assurance Nurse on 2/22/21 at 2:50 PM, the The Administrator began reading a text message that E#1 had sent on 1/7/21: "I got COVID as of 12/28/20. I'm recovering, on my 10th day of isolation..." The Administrator presented a physician's statement that included: "To Whom it May Concern... (E#1) was seen in my clinic on 1/7/2021 for covid-19 testing. The results of the covid-19 test are negative ..." During an interview with E#1 on 2/23/21 at 9:10 AM, E#1 stated he/she began exhibiting COVID-19 symptoms (sore throat, chills and body ache) on 2/27/20, and began self-quarantine at that time. E#1 stated that on 12/30/20 he/she received positive test results for COVID-19. On 1/7/21, E#1 notified the Administrator via text message of the positive COVID-19 test. E#1 stated he/she last provided service to Pt. #5 on 12/24/20. As of 2/22/21, the Agency lacked documentation the Agency initiated infection surveillance of E#1, as required by the Agency. 3. During an interview with the Administrator and the Quality Assurance Nurse dated 2/23/21 at 3:00 PM, the Administrator stated: "... (Pt.#6) began to feel ill on 9/20/20. Family noticed Pt. was fatigue and had a poor appetite. The RN called the doctor with this... the hospital tested for COVID and (Pt. #6)... was positive." 4. Pt. #6. SOC 4/28/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 2/23/21 at 1:30 PM. The record contained documentation that E#5 provided service to Pt. #6 on 9/14/20 and 9/16/20. As of 2/23/21, the Agency lacked any documentation of infection surveillance of E#5 due to exposure to COVID-19, and that E#5 was notified of his/her exposure to COVID-19. 5. On 2/23/21 at 2:50 PM, the Quality Assurance Nurse presented the Agency's Infection Control binder which contained a blank form titled, "COVID-19 Illness Tracking Form for Employees Reporting Symptoms/Exposure". The Quality Assurance Nurse stated this form is used for infection surveillance of the employees. This form contained questions pertaining to COVID-19 symptoms the employee is/was experiencing, contact and/or exposure within the past 14 days with individuals with COVID-19, United States and international travel within the past 14 days, inquiry regarding the community for which the employee resides being an area heavily populated with persons diagnosed with COVID-19, return to work guidelines and plan of action recommendations. The Agency lacked completed COVID-19 Illness Tracking Forms for E#1 and E#5. 6. During an interview with the Administrator and Quality Assurance Nurse on 2/23/21 at 2:55 PM, the Administrator and the Quality Assurance Nurse confirmed the Agency failed to implement its COVID-19 infection control surveillance for the employees.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. 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 Home Health Aide supervision was conducted every 14 days. This was found in 1 of 1 (Pt. #3) clinical records reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #3. SOC 2/22/20. Diagnoses: Bilateral Primary Osteoarthritits of Knee and Lumboscaral Region Spondylosis without Myelopathy or Radiculopathy. The clinical record was reviewed on 2/24/21 at 11:00 AM. The record contained weekly Home Health Aide visit notes from 12/23/20 to 2/11/21, indicating service was provided. The record also contained "Aide Supervisory Visit" notes completed by the PT dated 12/14/20, 1/11/21 and 2/8/21 (28 days without Aide supervision from 12/14/20 to 1/11/21 and 28 days without Aide supervision from 1/11/21 to 2/8/21). As of 2/23/21, the record lacked documentation the Home Health Aide was supervised every 14 days. 2. During an interview with the Administrator and Quality Assurance Nurse on 2/23/21 at 2:55 PM, the Administrator and the Quality Assurance Nurse confirmed the Home Health Aide was not supervised every 14 days.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . A. Based on observation and interview during home visits, clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure the clinical record contained accurate Medication Records. This was found in 4 of 7 (Pts. #1, 2, 3 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/28/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. A home visit was conducted on 2/23/21 at 2:30 PM, along with E #5. During the home visit, an observation was made of the Patient's Medication Record/Profile, which included "Glipizide 5 mg 1/2 tab(s) twice a day by mouth." Pt. #1's Caregiver provided a bottle of Glipizide 5 mg tablets, with the instructions printed on the pharmacy label "take one tablet twice a day by mouth." Pt. #1's Caregiver stated Pt. #1 has been taking a whole tablet (5 mg) "for awhile." The medication profile also contained, "Combivent Respimat Inhalation 20-100 mcg/act one puff three times a day as needed for shortness of breath." Pt. #1's Caregiver stated Pt. #1 takes "one puff every day..." The clinical record was reviewed on 2/23/21 at 10:00 AM. As of 2/23/21, the Medication Profile was not updated to include the correct dosage of Glipizide and Combivent Respimat. 2. Pt. #2. SOC 9/21/20. Primary Diagnosis: Heart Failure, Unspecified. A home visit was conducted on 2/23/21 at 1:15 PM with E #3. During the home visit, an observation was made of the Patient's Medication Profile, which included: "Aspirin 81 mg, one tablet by mouth daily." Pt. #2's Caregiver provided a bottle of Buffered Aspirin, 325 mg tablets. E #3 stated Pt. #2's Caregiver purchased this instead of the 81 mg tablets ordered by the Physician, and that Pt. #2's Physician said this was OK. The clinical record was reviewed on 2/22/21 at 2:15 PM. As of 2/23/21, the Medication Profile was not updated to include the correct dosage of the Aspirin. 3. Pt. #3. SOC 2/22/20. Diagnoses: Bilateral Primary Osteoarthritits of Knee and Lumboscaral Region Spondylosis without Myelopathy or Radiculopathy. The clinical record was reviewed on 2/24/21 at 11:00 AM. The record contained the form titled, "Patient Medication Record" completed by the RN for the certification period of 12/18/20 to 2/15/21. The "Patient Medication Record" contained: "Docusate Sodium Oral 100 MG 1 Cap(s) Daily". A home visit was conducted on 2/24/21 at 2:05 PM with the Administrator. During the home visit the patient's medications were observed, and an interview was conducted with the caregiver that stated: "A therapist and Aide come to see...(the Pt.). I give... Ducolox (Docusate Sodium)... 100 MG a capsule, 1 capsule three times a day." The caregiver stated the Physician and PT were aware that the Pt. receive 1 capsule three times a day. As of 2/24/21, the "Patient Medication Record" lacked the correct dosage of Ducolax (1 capsule three times a day, not 1 capsule one time a day), and the record lacked documentation the Agency contacted the Physician regarding this discrepancy. 4. Pt. #7. SOC 12/20/19. Diagnoses: Essential (Primary) Hypertension and History of Falling. The closed clinical record was reviewed on 2/23/21 at 1:50 PM. The record contained the form titled, "Patient Medication Record" completed by the RN for the certification period of 12/30/19 to 1/27/20. The record also contained the "Doctor's Order" dated 1/13/20 that included: "Dear Doctor (1) Please be advised on the pt's use of Restasis 0.05 %... 1 drop bilat eyes BID..." As of 2/23/21, the "Patient Medication Record" lacked Restasis. 5. The policy titled, "Medication Profile" was reviewed on 2/24/21 at 9:45 AM. The policy required: "the Registered Nurse or Therapist will complete a medication profile for each client... The profile will be reviewed, reconciled and updated as needed to reflect current medications the client is taking... PURPOSE... To provide documentation of the comprehensive assessment of all medications the client is currently taking and identify discrepancies between client profile and the physician and /or agency profile..." 6. During an interview with the Administrator and DON on 2/25/21 at 11:00 AM, the Administrator stated whenever there is a conflict in the Medication Record and what the Pt. is taking, the nurse or therapist is required to contact the Physician for clarification and update the Medication Record accordingly. 7. During an interview with the Administrator and Quality Assurance Nurse on 2/23/21 at 2:55 PM, and during an interview with the Administrator and DON on 2/25/21 from 11:10 AM to 11:55 AM, the Administrator, Quality Assurance Nurse and/or DON confirmed the Medications Records were inaccurate.