Every finding on record at Aspire Home Healthcare

The following reflects the findings of the California Department of Public Health during the Emergency Preparedness survey from 11/19/24 to 11/22/24. No deficiencies were identified from this survey.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 11/19/24 through 11/22/24. The agency reported a patient census of 332 during the survey. The number of unduplicated admissions for the past twelve months was 1319. The sample size was 17 patients with 5 home visits.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to document all resolutions on the complaint log for two of nine sampled complaints. As a result, the complaints may not have been resolved. Findings: On 11/21/24 a review was conducted of the agency’s undated Complaint Log. On 1/21/22 there was a complaint that a patient had been on service since 1/8/22 (13 days), and had not yet been seen by the physical therapist. There was no documentation of the agency’s response to the complaint. On 1/24/22 there was a complaint that the agency had not provided any visits to the patient in the two weeks they had been on service. There was no documentation of the agency’s response to the complaint. On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, he responded to the patient’s complaints, but did not document his response on the Complaint Log. Per the agency’s undated policy on complaints, titled Standard HH2-4A, “…A record of the complaint, investigation, follow-up action, outcome and response to the patient/family/caregiver is documented…”

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to admit a patient within 48 hours of the referral for two of 17 sampled patients (2, 12). As a result, patients had a delay in care and services. Findings: 1. Per the Home Health Certification and Plan of Care, dated 11/13/24 through 1/11/25, Patient 2 was admitted to the agency on 11/13/24 with diagnoses that included surgical aftercare (treatment to recover from surgery). A review of Patient 2's clinical record was conducted. Per the referral, dated 11/6/24, Patient 2 was referred to the agency, and on 11/6/24 the agency responded, “…Yes, willing to accept patient…” On 11/22/24 at 8:30 A.M., an interview was conducted with the Scheduler. The Scheduler stated, she received the referral for Patient 2 on 11/8/24, and she did not know why he was not admitted until 11/13/24. 2. Per the Home Health Certification and Plan of Care, dated 11/12/24 through 1/10/25, Patient 12 was admitted to the agency on 11/12/24 with diagnoses that included a fracture of the right lower leg (broken bone). A review of Patient 12's clinical record was conducted. Per the Printable Review Referral, dated 11/6/24, Patient 12 was referred to the agency. On 11/23/24 at 9:42 A.M., an interview was conducted with the Scheduler, and she stated she was not sure why the initial visit did not happen timely. The agency’s undated referral policy, titled Standard HH5-13A.01, did not direct staff to admit new patients within 48 hours of the referral.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete all evaluations within five days of the start of care for three of 17 sampled patients (1, 2, 8). As a result, the patient’s Plan of Care may not have included all patient needs. Findings: 1. Per the Home Health Certification and Plan of Care, dated 10/3/24 through 12/1/24, Patient 1 was admitted to the agency on 10/3/24 with diagnoses that included pneumonia (lung infection). The agency’s OT (Occupational Therapy – treatment to improve ability to do routine daily tasks) Evaluation for Patient 1 was dated 10/11/24 (eight days after admission). The agency’s PT (Physical Therapy – treatment to improve ability to move the body) Evaluation for Patient 1 was dated 10/11/24 (eight days after admission). 2. Per the Home Health Certification and Plan of Care, dated 11/13/24 through 1/11/25, Patient 2 was admitted to the agency on 11/13/24 with diagnoses that included surgical aftercare (treatment to recover from surgery). The agency’s ST (Speech Therapy - treatment to improve ability to speak) Evaluation for Patient 2 was dated 11/20/24 (seven days after admission). 3. Per the Home Health Certification and Plan of Care, dated 4/2/24 through 5/30/24, Patient 8 was admitted to the agency on 4/2/24 with diagnoses that included hemiplegia (inability to move part of the body). The agency’s PT Evaluation for Patient 8 was dated 4/9/24 (seven days after admission). On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, he did not require staff to complete their initial evaluation within a specific amount of time after admission. Per the agency’s policy, titled Standard HH5-2A.01, revised 11/11/16, “…The comprehensive assessment must be completed in a timely manner, consistent with patient’s immediate needs, but no later than 5 calendar days after the start of care…”

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 interview and record review, the agency failed to complete visit frequency order per the Plan of Care (POC) for three of 17 sampled patients (2, 10, 11). As a result, patients did not receive their needed care and services. 2. Per the Home Health Certification and Plan of Care, dated 8/27/24 through 10/25/24, Patient 10 was admitted to the agency on 6/28/24 with diagnoses that included a pressure ulcer (wound) to the sacral area (bottom of the spine). A review of Patient 10's clinical record was conducted. Per the POC, Patient 10 was to be seen by the Certified Home Health Aide (CHHA) twice a week. The week of 10/15/24 through 10/21/24, the CHHA visited Patient 10 once a week instead of two. 3. Per the Home Health Certification and Plan of Care, dated 8/28/24 through 10/26/24, Patient 11 was admitted to the agency on 7/5/23 with diagnoses that included a pressure ulcer (wound) to the left buttock. A review of Patient 11's clinical record was conducted. Per the POC, Patient 11 was to be seen by the Skilled Nurse (SN) once a week. The week of 9/8/24 through 9/14/24, no SN visit was made to Patient 11. On 11/22/24 at 10:42 A.M., a telephone interview and record review was conducted with the Regional Director of Nursing (RDON). The RDON stated visit frequency for Patient 10 and Patient 11 were missed. Per the agency's policy, titled Missed Visit, dated 11/28/08, "...Documentation of the missed visit will be entered into the medical record...." Findings: 1. Per the Home Health Certification and Plan of Care (POC), dated 11/13/24 through 1/11/25, Patient 2 was admitted to the agency on 11/13/24 with diagnoses that included surgical aftercare (treatment to recover from surgery), and directed the Physical Therapist (PT) to visit Patient 2 one time per week for four weeks. A review of Patient 2’s clinical record was conducted. On the week of 11/10/24 through 11/16/24 there were no documented PT visits. On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, Patient 2’s PT visit frequency should have been ordered to start later. The RDON further stated, the PT visit frequency was started too early, which resulted in a missed visit.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care was signed by the physician in a timely for three of 17 sampled patients (13, 14, 17). As a result, the agency could not ensure the physician had reviewed and approved the plan of care, treatment, and services provided. Findings: 1. Per the Home Health Certification and Plan of Care, dated 4/11/24 through 6/9/24, Patient 13 was admitted to the agency on 4/11/24 with diagnoses that included atrial fibrillation (irregular heartbeat). A review of Patient 13's clinical record was conducted. The Certification and Plan of Care, dated 4/11/24, was signed by the physician on 5/13/24. 2. Per the Home Health Certification and Plan of Care, dated 10/4/24 through 12/2/24, Patient 14 was admitted to the agency on 8/5/24 with diagnoses that included a fractured (broken) right femur (thigh bone). A review of Patient 14's clinical record was conducted. The Certification and Plan of Care, dated 10/4/24, was signed by the physician on 11/8/24. 3. Per the Home Health Certification and Plan of Care, dated 3/18/24 through 5/16/24, Patient 17 was admitted to the agency on 3/18/24 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-lung disease). A review of Patient 17's clinical record was conducted. The Certification and Plan of Care, dated 3/18/24, was signed by the physician on 5/7/24. On 11/22/24 at 10:42 A.M., a joint telephone interview and record review was conducted with the Regional Director of Nursing (RDON). The RDON stated the Certification and Plan of Care should have been signed by the physician within 30 days, and Patient 13, Patient 14, and Patient 17's plan of care had not been signed in a timely. Per the agency Standard HH5-4A Standard HH5-8A Standard HH5-8B, Verbal orders are only accepted by personnel authorized to do so by applicable State and Federal laws and regulations, as well as by the Agency's policy and procedure. Orders are to be signed by the physician within thirty (30) days of the receipt of the order.

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: Based on interview and record review, the agency failed to complete a discharge summary for one of four sampled discharged patients (7). As a result, a summary of Patient 7’s discharge was not available for review. Findings: Per the Home Health Certification and Plan of Care, dated 5/11/24 through 7/9/24, Patient 7 was admitted to the agency on 5/11/24 with diagnoses that included clavical fracture (collar bone break). On 11/21/24 at 11:12 A.M., a review was conducted of Patient 7’s clinical Record. The Discharge Summary had a target date of 5/28/24, and was marked as not yet started. On 11/22/24 at 9:06 A.M., a telephone interview was conducted with Skilled Nurse (SN) 5. SN 5 stated, he did not remember why the discharge summary was not completed for Patient 7. On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, there was a miscommunication at the time of Patient 7’s discharge, which caused the agency to not create the discharge summary in a timely manner. Per the agency’s policy on discharges, titled Standard 806A &1106A, dated 2010, “…The discharge summary should b e completed…The signed form becomes part of the patient’s home care record within five (5) days of discharge…”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interviews and record review, the agency failed to ensure a patient clinical record was accurate for one of 17 sampled patients (9). This failure resulted in inaccurate clinical records that could affect Patient 9's plan of care. Findings: Per the Home Health Certification and Plan of Care (POC), dated 10/22/24 through 12/20/24, Patient 9 was admitted to the agency on 10/22/24 with diagnoses that included Parkinson's Disease (a brain disorder that affects movement and other parts of the body). A review of Patient 9's clinical record was conducted. Per the PTA (Physical Therapy Assistant) Visit Note, the following entries were documented by PTA 3: On 10/24/24, PTA 3 documented Patient 9 stated, "He (Patient 9) fell yesterday..." On 10/31/24, PTA 3 documented Patient 9 stated, "He (Patient 9) fell yesterday..." On 11/5/24, PTA 3 documented Patient 9 stated, "He (Patient 9) fell yesterday..." On 11/7/24, PTA 3 documented Patient 9 stated, "He (Patient 9) fell yesterday..." On 11/21/24 at 8:10 A.M., an interview was conducted with Patient 9. Patient 9 stated he fell twice while under the care of the agency, which was the beginning of service and today [11/21/24]. On 11/22/24 at 8:29 A.M., an interview was conducted with PTA 3. PTA 3 stated their computer system allowed them to copy and forward their previous note to the current home visit. PTA 3 further stated it was an error in his documentation, and Patient 9 had one fall from 10/24/24 through 11/7/24. On 11/22/24 at 11:03 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated the clinician should document the patient's condition accurately. The agency could not provide policies and procedures for the accuracy of the clinical records.

The following reflects the findings of the California Department of Public Health during the Emergency Preparedness survey from 12/13/21 through 12/16/21. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 36471, HFEN 36708, and HFEN 39448. No deficiencies were identified from this survey.

The following reflects the findings of the California Department of Public Health during a home health recertification survey conducted from 12/13/21 through 12/16/21. The agency reported 1244 unduplicated admissions for the last 12 months. The total number of sampled patients was 17, and 7 home visits were conducted. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, 36471, 36708, and 39448. Glossary of Terms: DR - Director of Rehabilitation HHA – Home Health Agency LVN - Licensed Vocational Nurse PT – Physical Therapist RDCS – Regional Director of Clinical Services RN – Registered Nurse SN – Skilled Nurse

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to inform the patient that a discharge for cause (termination of care and service) was planned, for 1 of five closed record reviewed (5). As a result, there was a potential for Patient 5 to have an unsafe discharge. Findings: Per the Home Health Certification and Plan of Care, dated 10/14/21 through 12/12/21, Patient 5 was admitted to the agency on 10/14/21, with diagnoses which included disruption of surgical wound. A review of Patient 5’s clinical record was conducted. Per the Missed Visit Note, dated 10/28/21, SN 2 documented Patient 5 refused to be seen due to cold-like symptoms. Per the Visit Note, dated 11/1/21, Patient 5 was seen by SN 2 and documented that Patient 5 had wheezing sounds in all parts of the lungs. Per the Missed Visit Note, dated 11/4/21, SN 2 documented Patient 5’s door was locked and no answer. There was no documentation of an attempt to reschedule the home visit. In addition, there was no documentation that the HHA had considered a discharge for cause or that a conversation had taken place with Patient 5 regarding a discharge. Per the Agency’s list of Discharged Patients, Patient 5 was discharged on 11/11/21. Per the Home Health Discharge Summary, dated 11/13/21, SN 2 documented “…Patient called and reported out of town with daughter for 10 days, unfortunately patient will be discharged…” SN 2 was unavailable for interview. On 12/16/21 at 10 A.M., a joint interview and record review was conducted with the RDCS. The RDCS stated her expectation was for the staff to document attempts to resolve any issues prior to an agency-initiated discharge and to notify the physician about any changes to the plan of care. The RDCS further stated there should have been a communication note to discuss a discharge for cause for Patient 5 and there was none. Per the agency’s Standard of Practice, revised 11/11/16, “…The patient’s/family’s/caregiver’s involvement in/agreement to the plan of care and any revision to the plan are documented in the patient’s medical record…”

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 interview and record review, the agency failed to complete visits as ordered for 2 of 17 sampled patients (12, 13). As a result, patients did not receive the care and services ordered by the physician. Findings: 1. Per the Home Health Certification and Plan of Care dated 10/27/21 through 12/25/21, Patient 12 was admitted to the agency on 10/27/21, with diagnoses to include, subarachnoid hemorrhage (brain bleeding). Per the Physician Order, dated 11/17/21, SN was to visit Patient 12 one time on the week after the order. On 12/16/21 at 10:45 A.M., a concurrent interview and record review was conducted with the RDCS. The RDCS stated, there should have been an SN visit for Patient 12 on the week of 11/21/21, but it was not scheduled. The RDCS further stated, the SN should have documented a missed visit. On 12/16/21 at 11:30 A.M., a concurrent interview and record review was conducted with the Office Clerk. The Office Clerk stated, she scheduled a visit for Patient 12 on the week of 11/21/21, but the SN rescheduled the visit. The Office Clerk stated, the SN should have entered a communication note to explain the change in schedule. 2a. Per the Home Health Certification and Plan of Care dated 9/22/21 through 11/20/21, Patient 13 was admitted to the agency on 3/26/21, with diagnoses to include, Hemiplegia (paralysis of one side of the body). The Plan of Care included an order for a physical therapist to visit Patient 13 one time on the week of 9/22/21. On 12/16/21 at 10:10 A.M., an interview was conducted with the DR. The DR stated, the agency’s previous Office Clerk should have entered a physical therapy visit the week of 9/22/21, but they did not. The DR further stated, the ordered physical therapy visit was not completed, and a missed visit should have been entered for Patient 13 on the week of 9/22/21. 2b. Per the Physician Order, dated 9/27/21, the HHA was to visit Patient 13 two times per week for eight weeks. On 12/16/21 at 10:45 A.M., a concurrent interview and record review was conducted with the RDCS. The RDCS stated, there were two HHA visits scheduled for Patient 13 on 11/11/21, and one of the visits was marked as a duplicate and not completed. The RDCS further stated, the two visits should have been scheduled on two different days of the week, and the HHA should have documented a missed visit. On 12/16/21 at 11:30 A.M., a concurrent interview and record review was conducted with the Office Clerk. The Office Clerk stated, the previous Office Clerk should have scheduled the two HHA visits on 11/9 and 11/11 instead of both weekly visits on 11/11/21, which resulted in a duplicate visit. 2c. Per the Physician Order, dated 11/17/21, the SN was to visit Patient 13 one time on the week of the order. On 12/16/21 at 10:45 A.M., a concurrent interview and record review was conducted with the RDCS. The RDCS stated, there should have been an SN reevaluation visit for Patient 13 on the week of 11/19/21, but the visit was not done. The RDCS further stated, the SN should have documented a missed visit. On 12/16/21 at 11:30 A.M., a concurrent interview and record review was conducted with the Office Clerk. The Office Clerk stated, the previous Office Clerk should have entered the SN visit on the week of 11/17/21. Per the facility’s policy, titled Missed Visit, revised 12/19/20, “…all visits should be made in accordance with the designated Plan of Care… a reschedule of the visit will take place within the medicare week if possible as well as inform primary care doctor…”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to obtain physician signatures for the Certification and Plan of Care within 30 days of admission to the home health agency for 2 of 17 sampled patients (6, 7). As a result, the agency could not ensure the physician had reviewed and approved the plan of care, treatment, and services provided to Patients 6 and 7. Findings: 1. Per the Home Health Certification and Plan of Care, dated 11/10/21 through 1/8/22, Patient 6 was admitted to the agency on 10/2/17, with diagnoses that included quadriplegia (paralysis from the neck down, including the trunk, legs, and arms). A review was conducted of Patient 6's record. The Certification and Plan of Care, dated 11/10/21, was not signed by the physician. On 12/16/21 at 1:40 P.M., the RDCS was interviewed and stated it was important for the physician to have signed the plan of care as these were orders for care and treatment. The RDCS stated Patient 6's Certification and Plan of Care, dated 11/10/21 should have been signed by the physician within 30 days. The RDCS was unable to provide documentation to show attempts had been made to get the physician's signature. 2. Per the Home Health Certification and Plan of Care, dated 11/4/21 through 1/2/22, Patient 7 was admitted to the agency on 11/4/21, with diagnoses that included hemiplegia (paralysis of one side of the body). A review was conducted of Patient 7's record. The Certification and Plan of Care, dated 11/4/21, was not signed by the physician. On 12/16/21 1:40 P.M., the RDCS was interviewed and stated Patient 7's Certification and Plan of Care, dated 11/4/21 should have been signed by the physician within 30 days. When asked the importance of physician signatures on the Plan of Care, the RDCS stated the physician had to agree with the treatment and care plans for the patient. The RDCS was unable to provide documentation to show attempts had been made to get the physician's signature. The agency’s undated Standard: All personnel in the patient’s care are responsible for coordinating care effectively to support the objectives outlined in the patient’s plan of care indicated, “…Physician orders must be obtained before the initiation of care, treatment and/or services…The signed Plans of Care and modifying orders are filled in the patient’s medical record…” The agency’s Standard: Written policies describe the process for assessment and development of the plan of care, dated 11/16 indicated, “…the plan of care is reviewed…based upon the patient’s clinical status and/or needs for appropriateness, effectiveness, and to determine if all needed services/care are being provided…”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was aware of a patient’s change of condition and that the plan of care was not followed, for 1 of 17 sampled patients (5). As a result, there was a potential for Patient 5 not to receive care and services that were needed. Findings: Per the Home Health Certification and Plan of Care, dated 10/14/21 through 12/12/21, Patient 5 was admitted to the agency on 10/14/21, with diagnoses which included disruption of surgical wound. A review of Patient 5’s clinical record was conducted. Per the Missed Visit Note, dated 10/28/21, SN 2 documented Patient 5 refused to be seen due to cold-like symptoms. Under Physician Office Notified, SN 2 documented “No.” Per the Missed Visit Note, dated 11/4/21, SN 2 documented Patient 5’s door was locked and no answer. Under Physician Office Notified, SN 2 documented “No.” SN 2 was unable for interview. On 12/16/21 at 10 A.M., a joint interview and record review was conducted with the RDCS. The RDCS stated her expectation was for the SNs to notify the physician of Patient 5’s cold-like symptoms and request for the patient to be tested for covid or to have a chest x-ray. The RDCS further stated when there was an alteration to the plan of care such as inability to visit the patient, the physician should have been notified. Per the agency’s undated Standard of Practice, “…The Agency’s personnel promptly alert the physician to any changes that suggest need to alter the plan of care…The physician is notified of any change in the patient’s needs/clinical status…”

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete and document case conferences within 30 days for 4 of 17 sampled patients (3, 4, 6, 9). As a result, the agency could not ensure there was coordination of care and services for patients’ needs and an on-going communication amongst team members. Findings: 3. Per the Home Health Certification and Plan of Care, dated 11/10/21 through 1/8/22, Patient 6 was admitted to the agency on 10/2/17, with diagnoses that included quadriplegia (paralysis from the neck down, including the trunk, legs, and arms). Per the Oasis-D1, dated 11/5/21, Patient 6 had wounds. Patient 6’s Certification and Plan of Care dated 11/10/21, completed by SN 4, was reviewed. There was no documentation that indicated SN 4 had completed a 30-day case conference amongst other team members that discussed current progress or any on-going care and treatment for Patient 6. SN 4 was unavailable for interview. On 12/16/21 at 11:20 A.M., the RDCS was interviewed and stated a 30-day case conference was important to determine if the agency was still meeting the patient’s goals and progress, or the plan of care needed any revisions. The RDCS confirmed there was no case conference completed and documented for Patient 6. 4. Per the Home Health Certification and Plan of Care, dated 10/2/21 through 11/30/21, Patient 9 was admitted to the agency on 2/4/21, with diagnoses that included pressure ulcer (injury to the skin from prolonged pressure) of the right buttock. Patient 9’s Certification and Plan of Care dated 10/2/21, completed by SN 5, was reviewed. There was no documentation that indicated SN 5 held a 30-day case conference that discussed current progress or any on-going care and treatment for Patient 9. SN 5 was unavailable for interview. On 12/16/21 at 11:20 A.M., the RDCS was interviewed and stated a 30-day case conference was essential to determine if the agency was still meeting the patient’s goals and progress, or the plan of care needed any revisions. The RDCS confirmed there was no case conference held and documented for Patient 9. The agency’s undated Standard: All personnel in the patient’s care are responsible for coordinating care effectively to support the objectives outlined in the patient’s plan of care indicated, “…All personnel involved in the patient’s care are responsible for coordinating care effectively. Documentation of care coordination is expected every 30 days…” 1. Per the Home Health Certification and Plan of Care, dated 9/27/21 through 11/25/21, Patient 3 was admitted to the agency on 6/4/20, with diagnoses which included artificial openings of urinary tract. Patient 3 had SN and PT services. There was no documentation that indicated a 30-day case conference was conducted for Patient 3. 2. Per the Home Health Certification and Plan of Care, dated 11/2/21 through 12/31/21, Patient 4 was admitted to the agency on 7/5/21, with diagnoses which included chronic venous insufficiency (vein disease). Patient 4 had SN services. A review of Patient 4’s clinical records was conducted. There was no documentation that indicated a 30-day case conference was conducted for Patient 4. On 12/16/21 at 11:24 A.M., an interview and joint record review was conducted with the RDCS. The RDCS stated Patient 3 and Patient 4 did not have a case conference note every 30 days. The RDCS further stated the expectation was for the staff to document the case conference in the medical record. The agency’s undated Standard: All personnel in the patient’s care are responsible for coordinating care effectively to support the objectives outlined in the patient’s plan of care indicated, “…All personnel involved in the patient’s care are responsible for coordinating care effectively. Documentation of care coordination is expected every 30 days…”

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: Based on observation, interview and record review, the agency failed to ensure the infection control policy was followed when the SN obtained a clean gauze with an uncleaned gloved hand, for 1 of 17 sampled patients (2). As a result, there was a potential for cross-contamination of micro-organisms. Findings: Per the Home Health Certification and Plan of Care, dated 10/27/21 through 12/25/21, Patient 2 was admitted to the agency on 10/27/21, with diagnoses which included cellulitis (skin infection) of the right lower limb. On 12/14/21 at 8:45 A.M., an observation of Patient 2's wound dressing change was conducted by SN 1 during a home visit. With gloved hands, SN 1 cut the wound dressing with scissors and removed the soiled dressing from Patient 2’s skin. SN 1 reached into the package of clean gauze, and patted dry Patient 2’s wound. After the home visit an interview was conducted with SN 1. SN 1 stated she used her uncleaned gloved hand to get gauze from a clean package. SN 1 further stated she should have performed hand hygiene before getting the gauze to prevent cross-contamination. On 12/15/21 at 11:35 A.M., an interview was conducted with RDCS. The RDCS stated her expectation was for the staff to perform hand hygiene after contact with the (old) dressing. The RDCS further stated there was a breach of infection control practice when SN 1 did not remove the gloves and did not perform hand hygiene prior to getting the clean gauze from the package. Per the agency’s undated, Standard of Practice, Subject: Hand Hygiene, “…After coming in contact with patient … After contact with…wound dressing… After contact with medical equipment and supplies… Change gloves when moving from a contaminated body site to a clean body site…”

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to develop a plan of care related to wound treatments for 1 of 17 sampled patients (6). As a result, the progress or deterioration of the wound could not accurately be assessed. Findings: Per the Home Health Certification and Plan of Care, dated 11/10/21 through 1/8/22, Patient 6 was admitted to the agency on 10/2/17, with diagnoses that included quadriplegia (paralysis from the neck down, including the trunk, legs, and arms). Per the Oasis-D1, dated 11/5/21, Patient 6 had wounds. The Plan of Care and Oasis-D1 were completed by SN 4. Patient 6’s Certification and Plan of Care dated 11/10/21 was reviewed. There were no physician orders for wound treatment. SN visit notes for this certification period were reviewed, there were no wound assessments and wound measurements completed by the visiting nurses. SN 4 was unavailable for interview. On 12/14/21 at 12:30 P.M., a joint home visit for Patient 6 was conducted with SN 6. SN 6 did not perform any wound treatment for Patient 6 during the visit. SN 6 asked Patient 6 the status of the wounds in the buttock area, and Patient 6 stated the caregivers were changing the dressings and applying some cream treatment. On 12/16/21 at 9:45 A.M., a concurrent record review and interview with SN 6 was conducted. SN 6 confirmed there were no physician orders for treatment in the plan of care and that his assessments during home visits were missing wound assessments and measurements. On 12/16/21 at 1:40 P.M., the RDCS was interviewed and stated the plan of care should have reflected all the necessary care and treatment the patient needed. The agency’s undated Standard: All personnel in the patient’s care are responsible for coordinating care effectively to support the objectives outlined in the patient’s plan of care indicated, “…All clinical services are implemented only in accordance with a plan of care established by a physician’s written orders…” The agency’s undated policy and procedure titled Wound Assessment and Documentation indicated, “…Document the following on the visit report: The treatment and condition of the wound (each visit), appearance of the wound bed…wound measurements…”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure RNs supervised the LVNs and evaluated the nursing care and assessments for 2 of 17 patients (6, 9). As a result, the agency could not assure the LVN performed the necessary care, treatment, and education to the patient. Findings: 1. Per the Home Health Certification and Plan of Care, dated 11/10/21 through 1/8/22, Patient 6 was admitted to the agency on 10/2/17, with diagnoses that included quadriplegia (paralysis from the neck down, including the trunk, legs, and arms). Patient 6’s Certification and Plan of Care dated 11/10/21, completed by SN 4, was reviewed. SN 4 was an RN. The succeeding visits were all completed by SN 6 who was an LVN. There was no supervisory visit conducted and completed by the RN after 30 days. On 12/16/21 at 9:45 A.M., a concurrent record review and interview with SN 6 was conducted. SN 6 confirmed there were no supervisory visits done past 30 days of visiting the patient. SN 6 stated there should have been a supervisory visit with the RN. SN 4 was unavailable for interview. On 12/16/21 at 2 P.M., the RDCS was interviewed and stated supervisory visits for the LVN were completed after 30 days and should be documented. The RDCS confirmed there was no supervisory visits completed for Patient 6. 2. Per the Home Health Certification and Plan of Care, dated 6/27/21 through 8/25/21, Patient 10 was admitted to the agency on 4/28/21, with diagnoses that included hypertension (high blood pressure) and chronic kidney disease (slow loss of kidney function over time). Patient 10’s Certification and Plan of Care dated 6/27/21, completed by SN 27 was reviewed. SN 27 was an RN. The succeeding visits were all completed by SN 6 who was an LVN. There was no supervisory visit conducted and completed by the RN after 30 days. On 12/16/21 at 9:45 A.M., a concurrent record review and interview with SN 6 was conducted. SN 6 confirmed there were no supervisory visits done past 30 days of visiting the patient. SN 6 stated there should have been a supervisory visit with the RN. SN 27 was unavailable for interview. On 12/16/21 at 2 P.M., the RDCS was interviewed and stated supervisory visits for the LVN were completed after 30 days and should be documented. The RDCS confirmed there were no supervisory visits completed for Patient 10. The agency’s undated Standard: The Agency has written policies and procedures relating to the supervision of new and experienced personnel, indicated, “…Licensed Vocational Nurses are evaluated at least every four (4) weeks by an appropriately qualified and experienced registered Nurse…”

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate and follow the hospital referral order, for 1 of 17 sampled patients (5). As a result, Patient 5 did not receive care and services that were needed. Findings: Per the Home Health Certification and Plan of Care, dated 10/14/21 through 12/12/21, Patient 5 was admitted to the agency on 10/14/21, with diagnoses which included disruption of surgical wound. A review of Patient 5’s clinical record was conducted. Per the Hospital Discharge Order, dated 10/12/21, Patient 5 was to be seen by the Social Worker. There was no indication that Patient 5 was seen by the Agency’s Social Worker. On 12/16/21 at 2:52 P.M., a joint interview and record review was conducted with the RDCS. The RDCS stated her expectation was for the staff to follow all the orders from the hospital, coordinate care and services, and document in the patient’s medical record. The RDCS stated Patient 5 had a referral to be seen by the social worker and it did not happen. The RDCS further stated she was unsure why the order was omitted and there was no documentation as to why the social worker was not provided by the agency. Per the agency's undated, Standard of Practice, “Standard: All personnel involved in the patient’s care are responsible for coordinating care…”

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: Based on interview and record review, the agency failed to complete a discharge summary for 1 of 17 sampled patients (11) after being discharged from the home health agency. This failure did not ensure Patient 11 had received care and services per the plan of care and the goals of treatment were met. Findings: Per the Home Health Certification and Plan of Care, dated 8/31/21 through 10/29/21, Patient 11 was admitted to the agency on 7/2/21, with diagnoses that included myasthenia gravis (disease that causes weakness in the voluntary muscles). Patient 11’s Certification and Plan of Care dated 8/31/21 was reviewed. SN was to visit once a week for one week, PT was to visit once a week for four weeks. The PT’s visit dated 9/28/21 was titled PT Discharge, however, it indicated a missed visit and there was no other evidence of documentation of a discharge summary completed by the PT. The PT was unavailable for interview. On 12/16/21 at 11:10 A.M., an interview with the DR was conducted. The DR stated when disciplines discharge a patient, a discharge summary had to be done to show that services were completed, and goals have been met. The DR confirmed there was no discharge summary completed by the PT for Patient 11. The agency’s policy titled Discharge/Transfer/Referral of Patients, dated 6/09, indicated, “…The discharge summary should be completed by each skilled service…The signed form becomes a part of the patient’s home care record within five (5) days of discharge…”