Every finding on record at Assisted Home Recovery, Inc.

The following reflects the findings of the Department of Public Health during a recertification survey. Representing the Department of Public Health: Surveyor: 43929, RN-Health Facilities Evaluator Nurse Surveyor: 19096, RN-Health Facilities Evaluator Nurse Unduplicated Admission: Active Patients: Sample Size: 17 Home visits: 7

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to accurately reflect the patient’s status of the pressure sore that include measurement at least weekly noting width, length and depth in the comprehensive assessment for 1 of 17 sampled patients (Patient 13). This failure resulted in the comprehensive assessment missing relevant active medical information. Findings: Patient 13’s record was reviewed. The form titled “Home Health Certification and Plan of Care” (POC), certification period 4/12/22 to 6/10/22, indicated the start of care (SOC) date for Patient 13 was 4/12/22, with diagnosis of pressure ulcer of sacral region, stage 2 (a skin injury caused by pressure resulting in an opening exposing the skin). During an interview on 5/15/22, at 10:38 a.m., the Director of Patient Care Services stated wound measurements were supposed to be taken on initial assessment. During an interview on 5/15/22, at 10:46 a.m., the Registered Nurse Supervisor (RN supervisor) stated wound measurements are important to see the progress of the wound. A review of Patient 13’s record titled “SN Nursing OASIS start of care”, dated 4/12/22, indicated “Stage of most problematic unhealed pressure ulcer/injury that is stageable: 2-stage 2.” Further review of the record did not indicate the measurements of the pressure sore. A review of Patient 13’s record titled “Charts/Clinical Notes”, dated 4/12/22, indicated “Stage 2 pressure ulcer noted to the left buttock…Stage 2 pressure ulcer to the intergluteal left…” Further review of the record did not indicate the measurements of the pressure sore. A review of the HHA’s policy and procedure titled “Management of Wound and Pressure Injuries”, revised 9/21, indicated “Wounds are to be measured at least weekly noting width, length and depth, color drainage and condition of surrounding tissue. The wound skin surface dimensions is measured as length x width…Wound assessment and care documented in the computer will be located in the Patient Assessment, Clinical notes and/or Visit Record”.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency failed to review all the medications the patient was currently taking, when conducting home visits, for 1 of 17 sampled patients (Patient 10). This failure resulted in the lack of medications reconciliation which had the potential in placing the patient at risk for medication errors and adverse drug reactions. Findings: Patient 10’s record was reviewed. The form titled “Home Health Certification and Plan of Care” (POC), certification period 4/28/22 to 6/26/22, indicated the start of care (SOC) date for Patient 10 was 4/28/22, with diagnosis which included aftercare following exploration of hip joint prosthesis (hip replacement). During a home visit on 5/14/22, at 4:00 p.m., Registered Nurse 1 (RN 1) was observed providing care to Patient 10. RN 1 did not review the medications Patient 10 was taking. During an interview, on 5/14/22, at 4:45 p.m., RN 1 stated “we are supposed to check the medications every visit, with him every week. I always ask him if there’s any changes. He says no”. During an interview on 5/15/22, at 11:30 a.m., the Director of Patient Care Services (DPCS) stated “We are supposed to review the medications every visit. Reviewing the medications means we look at the bottles of medication and compare it to the medication list to make sure it correlates. We also ask the patient if there are any changes. This is important because we can see if there are any potential drug interactions, especially if there are new medications.” A review of Patient 10’s record titled, “SN nursing”, dated 4/29/22, indicated “Pt. does not have medications/no med reconciliation performed this visit” A review of Patient 10’s record titled, “SN nursing”, dated 5/5/22, indicated “Pt. does not have medications/no med reconciliation performed this visit” A review of Patient 10’s record titled, “SN nursing”, dated 5/8/22, indicated “Pt. does not have medications/no med reconciliation performed this visit” A review of Patient 10’s record titled, “SN nursing”, dated 5/11/22, indicated “Pt. does not have medications/no med reconciliation performed this visit” A review of Patient 10’s record titled, “Medication List”, dated 5/13/22, listed 9 medications. A review of the HHA’s policy and procedure titled, “Medication management”, revised on 9/21, indicated “A complete medication reconciliation shall be performed to identify potentially clinically significant medication issues…”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency failed to ensure all physician’s orders were included in the plan of care for 2 of 17 sampled patients (Patient 10 and Patient 13). This failure resulted in the patients' care plans not reflecting the most updated care the patients were receiving. Findings: 1. Patient 10’s record was reviewed. The form titled “Home Health Certification and Plan of Care” (POC), certification period 4/28/22 to 6/26/22, indicated the start of care (SOC) date for Patient 10 was 4/28/22, with diagnosis which included aftercare following exploration of hip joint prosthesis (hip replacement). During a home visit on 5/14/22, at 4:00 p.m., Registered Nurse 1 (RN 1) was observed providing surgical wound care to Patient 10. RN 1 was observed removing the dressing from the wound, cleaning with chloraprep (a form of antisceptic), and covering the wound. During an interview on 5/14/22, at 4:30 p.m., RN 1 stated “Per MD orders, I am supposed to clean with chloraprep only and apply a beige foam mephelex (a specialized dressing) dressing only”. During a concurrent interview and record review on 5/15/22, at 9:25 a.m., Patient 10’s record titled “Home Health Certification and Plan of Care” (POC), certification period 4/28/22 to 6/26/22, was reviewed with the Director of Patient Care Services (DPCS). The DPCS stated “I don’t see the wound care instructions on the plan of care. Wound care treatment instructions should be on the plan of care. This is important because it tells us what we should do for the patient”. 2. Patient 13’s record was reviewed. The form titled “Home Health Certification and Plan of Care” (POC), certification period 4/12/22 to 6/10/22, indicated the start of care (SOC) date for Patient 13 was 4/12/22, with diagnosis which included pressure ulcer of sacral region, stage 2 (a skin injury caused by pressure resulting in an opening exposing the skin). During a concurrent interview and record review on 5/15/22, at 10:30 a.m., Patient 13’s form titled “Home Health Certification and Plan of Care” (POC), certification period 4/28/22 to 6/26/22, was reviewed with the DPCS. The DPCS stated there was no order for wound care on the SOC, but the agency was able to get an order on the same day, 4/12/22. The DPCS stated the agency had time to update the plan of care. The DPCS stated the plan of care has to “have everything in it like the frequency and what specific wound treatment the patient will get.” A review of the HHA’s policy and procedure titled “Plan of Care”, revised on 7/17, indicated “The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment…the individualized plan of care includes, but is not limited to…all medications and treatments…”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: A review of Patient 4's clinical record indicated a start of care date of 3/25/2022, with diagnosis of complete traumatic amputation at level between right hip and knee, diabetes mellitus ( High blood), chronic Kidney disease ( a longstanding disease of the kidneys leading to renal failure.) and reduced mobility. The physician orders the Physical Therapist (PT) to evaluate, visit the patient one time a week for one week, then two times a week for four weeks to assess all systems including vital signs and pain every visit, assess/ instruct on basic home safety, gait training, balance training. Review of Patient 4 comprehensive assessment by PT pain assessment was incomplete and there was no information about patient 4 being a diabetic. During a a phone interview with Patient 4 on 5/10/2022, at 12: 30 p.m, n Patient 4 stated he is new to this agency and is thinking about going back to his old HHA this agency due to this agency only providing PT when he has issues sometimes with his blood pressure being high and the old agency included skill nurse visit as well as Certified Home Health aid services. A review of Patient 4’se PT notes dated 4/1/22. Indicate patient 4’s pain level 5/10. PTA notes dated 4/6/22 indicated patient 4’s pain level 6/10. PTA notes dated 4/11/2022 document patient 4’s pain level of 7/10. PTA notes dated 4/13/2022, indicate patient 4’s pain level 9/10. PTA notes dated 4/18/2022, indicate a pain level of 8/10 PT notes dated 4/21/22, indicated no pain. PTA notes Dated 5/4/2022, indicates a pain level o 7/10 During an interview and record review with the Director of pateient care services on 5/15/2022 at 10:52 am., she stated The PT is supposed to call here to the HHA and notify us and call patient 4’s the physician and notify him of patients pain levels. She stated they are supposed to do vital signs before and after Physical therapy especially there is pain. The DPCS state PT needs to report the location of the pain and should have re-evaluated patient 4’s vital signs after therapy. A review of the HHA’s policy and Procedure on Pain Management End of Life Care revised 1/10 stipulates,” The Agency will treat, consult or refer patients to other providers to meet their pain and end of life needs.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure the patient's medical record included the assessment of the wound measurement for 1 of 17 sampled patients (Patient 13). This failure resulted in the patient's incomplete medical record. Findings: Patient 13’s record was reviewed. The form titled “Home Health Certification and Plan of Care” (POC), certification period 4/12/22 to 6/10/22, indicated the start of care (SOC) date for Patient 13 was 4/12/22, with diagnosis which included pressure ulcer of sacral region, stage 2 (a skin injury caused by pressure resulting in an opening exposing the skin). During an interview on 5/15/22, at 10:38 a.m., the Director of Patient Care Services (DPCS) stated wound measurements were supposed to be taken on initial assessment and then weekly. During an interview on 5/15/22, at 10:46 a.m., the Registered Nurse Supervisor (RN supervisor) stated wound measurements are important to see the progress of the wound. During a concurrent interview and record review on 5/15/22, at 11:25 a.m., Patient 13’s records titled “SN-OASIS Start of Care”, dated 4/12/22 and “SN nursing notes”, dated 5/5/22 were reviewed with the DPCS. The records did not indicate wound measurements. The DCPS stated the measurements should be there; if they are not documented, they were not done. A review of the HHA’s policy and procedure titled “Management of Wound and Pressure Injuries”, revised 9/21, indicated “Wounds are to be measured at least weekly noting width, length…”