Every finding on record at Assisted Home Care, Inc

The following reflects the findings of the Department of Public Health during a recertification survey. Representing the Department of Pubic Health: Surveyor #: 19096 Surveyor #: 09697 Surveyor #: 43929 Sample size: 18 Home visits : 7

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patient's need for humidified oxygen for 1 out of 18 sampled patients ( Patient 12). This deficient practice had the potential to cause dry nasal dryness and possible nose bleed and other complications to the patient. Findings: During a review of Patient 12's " Home Health Certification and Plan of Care", (POC) indicated Patient 12's start of care date with the agency was 8/27/2018. The POC with the certification period 12/9/2021 to 2/6/2022, indicated Patient 12's primary diagnoses included Alpha -1- antitrypsin deficiency [a genetic (inherited) condition passed from parents to their children through their genes and causes an increase in chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and liver disease. The POC indicated Patient 12 was oriented and able to make decisions. A home visit was conducted at Patient 12's house on 1/12/2022, at 10: 00 am., Patient 12 was observed sitting on her couch with nasal cannulas in both nares connected to a long oxygen tubing. The Skilled Nurse (SN) was observed taking Patient 12's vital signs and hanging patient 12's intravenous Prolactin-c (a medication used weekly for patients with Alpha 1 antitrypsin deficiency to raises levels on the frequency of pulmonary exacerbations and the progression of emphysema) 60 mg/kg once a week. During an interview with Patient 12 on 1/12/ 2022, at 11:00 a.m., she stated she had been on oxygen at 3 liters/minute continuous for five years due to her hereditary illness. She stated the use of oxygen really dry out her nose. Patient 12 also stated that she has been with this HHA for about three years. When she was asked if she was using humidified water bottle on her oxygen concentrator, Patient 12 stated she was never informed of that and she would like to try it, instead of using a humidifier in the house. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 1/12/2022, at 11: 30 a.m., LVN 1 stated she never bothered to assess or inform Patient 12 regarding the use of humidified water with her oxygen concentrator due to the length of the oxygen tubing used, that was at least fifty feet to get around the house, and that the tubing had required to be changed weekly instead of monthly due to the moisture built up in the tubing. During an interview with Registered Nurse 1 (RN 1) on 1/13/2022 at 12;30 p.m., in the HHA conference room, RN 1 stated that Patient 12 should have been informed and offered the humified oxygen option and able to make her own decision regarding the use of humidified oxygen.

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 assess for referrals, five of 18 sampled patients, (Patients 8, 9, 10, 11 and 13) within 48 hours. This deficient practice resulted in delay of care for the five patients under the agency's care. Findings: 1. During an interview and concurrent record review on 1/13/2021, at 2:51 p.m., Patient 8’s undated medical record titled, “Intake” was reviewed with Registered Nurse 1 (RN 1). RN 1 stated Patient 8 was referred to the facility on 12/21/2021 and the initial assessment/care was started on 12/28/2021 by physical therapy. During an interview on 1/14/2022, at 10:30 a.m., with RN 1, she stated the reason for the delay in starting care for Patient 8 was insufficient staffing. RN 1 did not provide a physician’s order to begin care for Patient 8 on 12/28/2021. A review of Patient 8’s medical record titled, “Physical Therapy OASIS D1”, dated 12/28/2021, indicated the patient was assessed on 12/28/2021. 2. A review of Patient 9’s record titled, “Patient Information”, dated 1/6/2022, indicated Patient 9 was admitted to the agency on 08/05/2021, with diagnosis of acute embolism (blood clot that obstructs blood flow). During an interview and concurrent record review on 1/13/2021, at 3:04 p.m., Patient 9’s medical record titled “Agency Discharge Summary”, dated 8/11/2021, was reviewed with RN 1. The medical record indicated Patient 9’s referral date was 7/30/21 and the date of admission was 8/5/2021. RN 1 stated the reason for the delay was due to the patient not responding to agency phone calls. RN 1 stated the Doctor was notified of the delay to start care on 8/5/2021, however; RN 1 cannot provide a physician’s order to begin care on 8/5/2021. A review of Patient 9’s medical record titled, “Physical Therapy OASIS D1”, dated 8/5/2021, indicated 3. A review of Patient 10’s medical record titled, “Patient Information”, dated 8/24/2021, indicated Patient 10 was admitted to the agency on 8/24/2021, with diagnosis of malignant neoplasm of pylorus (stomach cancer). During an interview and concurrent record review on 1/13/2022, at 1:39 p.m., Patient 10’s medical record titled “Agency Discharge Summary”, dated 10/13/2021, the medical record indicated Patient 10’s referral date was 8/18/2021 and the date of admission was 8/24/2021. Registered Nurse 2 (RN 2) stated there was a delay in starting care for Patient 10. RN 2 stated the Doctor was notified of the delay on 8/24/2021, however, RN 2 cannot provide a physician’s order to begin care on 8/24/2021. A review of Patient 10’s medical record titled, “Start of Care Comprehensive Adult Nursing Assessment”, dated 8/24/2021, indicated the patient was assessed on 8/24/2021. 3. A review of Patient 11’s medical record titled, “Patient Information”, dated 1/6/2022, indicated Patient 11 was admitted to the agency on 1/6/2022, with diagnosis of aftercare following joint replacement surgery. During an interview and concurrent record review on 1/14/2022, at 11:50 a.m., Patient 11’s medical record titled “Intake” and “Home Health Certification and Plan of Care”, for certification period 1/6/2022 to 3/6/2022, the record was reviewed with RN 1. RN 1 stated Patient 11 was referred to the agency on 1/3/2022 and the care was started on 1/6/2022. RN 1 stated there was no explanation to explain the delay in starting care for Patient 11. RN 1 was unable to provide a physician’s order to begin care on 1/6/2022. A review of Patient 11’s medical record titled, “Physical Therapy OASIS D1”, dated 1/6/2021, and Patient 11 was assessed on 1/6/2021. 5. A review of Patient’s 13’s medical record titled, “Patient Information”, dated 1/6/2022, indicated Patient 13 was admitted to the agency on 12/15/2021, with diagnosis of Crohn’s disease (a type of inflammatory bowel disease). Further review of Patient 13’s undated medical record titled, “Intake”, indicated referral date 12/8/2021 and start of care date 12/15/2021. A review of Patient 13’s medical record titled “Charts/Clinical Notes”, dated 12/9/2021, indicated, “Delay in SOC due to medication delivery”. There was no documentation the Doctor was notified on 12/9/2021. During an interview on 1/14/2022, at 11:50 a.m., Staff 1 (S 1) indicated the agency should have known there was a delay in start of care by 24 hours from the referral date and should have notified the Doctor, however S1 stated the doctor was notified on 12/13/2021. A review of the facility’s policy and procedure titled, “Admission Criteria”, dated 11/2017, indicated, “Patients shall routinely be seen within 24-48 hours from receipt of referral, as appropriate to meet the patient’s need or as specified by the physician’s order and or the patient/family preference.” A review of the facility’s policy and procedure titled, “Physician Reporting and Communication”, dated 5/2018, indicated “All physician contact shall be completely documented in the patient’s medical record.”

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 interview and record review, the facility failed to ensure vital sign parameters (normal ranges for blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation) were written in the plan of care for 1 of 18 sampled patients (Patient 10). This deficient practice placed Patient 10 at risk for health complications and no interventions when when the patient's vital signs are out of range. Findings: During an interview and concurrent record review on 1/12/2022, at 12:45 p.m., Staff 2 stated vital sign parameters were not written on the plan of care because staff were directed to follow the agency’s policy parameters. Staff 2 stated the parameters for vital signs were as follows: Blood pressure systolic above 180 or below 100; Pulse: 60-80 beats per minute, at rest; Respiratory rate: 14-18 breaths per minute; Temperature: 96.8-99.0 degrees Fahrenheit, oxygen saturation above 92% When asked, Staff 2 stated if the ranges were above or below, she would call the supervisor before making any treatments and report the values to the doctor. During an interview on 1/13/2022, at 10:15 a.m., the Director of Nursing (DON) stated all staffs are notified of the agency’s parameters frequently. A review of the facility’s policy and procedure titled, “Physician Reporting and Communication”, dated 5/18, indicated situations requiring physician contact are the following: presence of temperature elevation of 101 degrees or presence of hypothermia within 4 hours from the time detected; presence of blood pressure reading of less than 85 or greater than 180 systolic or less than 50 or greater than 110 diastolic within 4 hours from the time detected; presence of pulse less than 50 (or 60 if the patient is on a beta blocker) or greater than 120 within 4 hours from the time detected.” The document (facility's policy) did not include parameters for respiratory rate and oxygen saturation.

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 interview and record review, the agency failed to inform the attending physician for one of 18 sampled patients (Patient 14), regarding his refusal for home health aide (HHA) staff visits and care. This failure resulted in the lack of communication with the patient's physician which had the potential to affect the patient's physical health. Findings: A review of Patient 14's clinical record indicated a start of care date of 11/6/2021. During the first certification period dated 11/6/2021 through 1/4/2022, Patient 14's plan of care indicated primary diagnoses of multiple pressure sore stage 4, diabetes mellitus (abnormal blood sugar levels), colostomy (stoma to pass feces) and with indwelling catheter (catheter to drain urine). Patient 14 required extensive assistance with his activities of daily living. The physician's order in the plan of care indicated skilled nursing visit 1-2 visits per week for two weeks; physical therapy (PT) once a week for one week. A review of the clinical record for Patient 14 titled "Home Health Aid Assignment sheet" indicated documentation by an RN dated 11/6/2021, to meet personal care needs twice a week for 8 weeks. During the week of 11/6/2021 through 11/13/2021, and 11/14/21 through 11/21/2021, there were no documentations that indicated HHA visits to provide personal care to Patient 14. During an interview on 1/12/2022, at 2 p.m., Registered Nurse 2 (RN 2) stated that during those times, Patient 14 had refused care provided by HHA staff. RN 2 stated the following week, Patient 14 agreed to be cared for by the family members. However, there were no documentations that the refusal of care had been communicated to the physician.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to maintain an accurate home visit record for 2 of 18 sampled patients (Patient 8 and Patient 10). This failure resulted in incorrect information regarding the time the services were given. Findings: a. A review of Patient 8’s medical record titled, “Visit Record”, dated 12/28/2021, indicated “Time in 1:30 p.m., Time out 2:30 p.m.” A review of Patient 8’s medical record titled, “Physical Therapy Start of Care”, dated 12/28/2021, indicated “Temperature 05:34 p.m.”, “Pulse 05:34 p.m.”, “Respiration 05:34 p.m.”, “Blood Pressure 05:34 p.m.” During an interview on 1/13/2022 at 2:15 p.m., Registered Nurse 2 (RN 2) stated the time on vital signs should be accurate. RN 2 stated the time on the vital sign area should reflect the time vital signs were taken. b. A review of Patient 10’s medical record titled, ““Visit Record”, dated 8/27/2021, indicated, “Time in 5:15 p.m., Time out 6:45 p.m.” Further review of Patient 10’s medical record titled, “SN-Nursing”, dated 8/27/2021, indicated “Temperature 11:10 a.m.”, “Pulse 11:10 p.m.”, “Respiration 11:10 p.m.”, “Blood Pressure 11:10 p.m.” A review of the facility’s policy and procedure titled, “Clinical Visit Notes”, dated 7/19, indicated “Each time staff provides care, the home care record contains notes which include…The time and date the care was provided. Documentation of the home visit shall be submitted to meet regulatory guidelines.”