Every finding on record at At Home Infucare LLC

An unannounced Emergency Preparedness survey, which ended on 3/9/22, was conducted at At Home Care Agency. This home health agency was determined to be out of compliance with an Emergency Preparedness requirement.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(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 facilities]. 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: Based on policy review and document review, it was determined the agency failed to include the names and contact information of patient’s physicians in the agency’s Emergency Preparedness Communication Plan. Findings included: Review of the agency's emergency preparedness policies/procedures revealed no evidence of: the names and contact information of patient’s physicians in the agency’s Emergency Preparedness Communication Plan The finding was confirmed by the Clinical Director on 3/8/2022 between 1:30 PM – 4:08 PM.

An extended recertification survey, which ended on 3/9/2022, was conducted at At Home Care Agency for the purpose of determining the agency's compliance with Medicare requirements. Survey activities included review of 7 clinical records, 2 home visits, policy review, review of other agency documents and interviews with patients and staff. The agency was determined to be out of compliance with the following condition and standards as required by 42 CFR Part 484, Requirements for Home Health Agencies.

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on OASIS report review and staff interview, it was determined that the agency failed to electronically report all OASIS data collected in accordance with 484.55. Findings included: iQIES report titled “HHA List – No Successful Production Submissions Report” completed on 2/25/2022 indicated At Home Care Agency, CCN #087043, had no OASIS Submission and no Accepted OASIS Records for the date range 1/1/2021 – 12/31/2021. iQIES report titled “HHA Roster Report” completed for At Home Care Agency on 2/25/2022 revealed no results. iQIES report titled “HHA Discharge Report” completed for At Home Care Agency on 2/25/2022 revealed no results. iQIES report titled “At Home Care Agency Potentially Avoidable Events” completed on 2/28/2022 revealed no results. Interview with Director on 3/1/2022 at 12:18 PM revealed that the agency has not submitted OASIS data since they lost JACHO (Joint Commission on Accreditation of Healthcare Organizations) accreditation in 2020. The Director states they are not billing Medicare but did state they are billing Delaware Medicaid. Confirmed findings with the Director on 3/1/2022 at 12:18 PM the agency failed to electronically report all OASIS data collected in accordance with 484.55.

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 clinical record review, policy review and staff interview, it was determined that: for 2 of 7 patients (Patients #2, #5) in the sample, the Comprehensive Assessment failed to include information about the patient’s current health status. Findings included: The agency policy entitled “Comprehensive Assessment” stated, “…The Comprehensive Assessment also includes the completion of the applicable OASIS data set items…the Comprehensive Assessment shall include the following information…the patient’s problems, needs, strengths, including current health…status…” Patient #2 Review of medical record revealed: The agency’s “Recertification/Follow-up Assessment” dated 7/22/2021 documented the patient diagnosis of Diabetes Type 2. The agency’s “Recertification/Follow-up Assessment” dated 7/22/2021 documented that a diabetic foot exam was not applicable, there was no evidence of an assessment of the feet or foot care information provided, and there was no evidence that the patient’s diabetic management information provided. These findings were confirmed with the Alternate Clinical Director on 3/9/2022 at 11:32 AM. Patient #5 Review of medical record revealed: The agency’s “Recertification/Follow-up Assessment” dated 1/14/2022 documented the patient diagnosis of Diabetes and Diabetic Neuropathy. The agency’s “Recertification/Follow-up Assessment” dated 1/14/2022 documented that a diabetic foot exam was not applicable, there was no evidence of an assessment of the feet or foot care information provided, and there was no evidence that the patient’s diabetic management information provided. These findings were confirmed with the Alternate Clinical Director on 3/9/2022 at 11:50 AM.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and staff interview, it was determined that: for 2 of 7 patients (Patients #2, #5) in the sample, the Comprehensive Assessment failed to include information about the patient’s strengths, limitations, and care preferences. Findings included: The agency policy entitled “Comprehensive Assessment” stated, “…The Comprehensive Assessment also includes the completion of the applicable OASIS data set items…the Comprehensive Assessment shall include the following information…the patient’s problems, needs, strengths…The patient’s wishes regarding care, treatment, and services…” Patient #2 Review of medical record revealed: The agency’s “Recertification/Follow-up Assessment” dated 7/22/2021 failed to provide evidence that of the patient’s strengths, limitations, and care preferences. These findings were confirmed with the Alternate Clinical Director on 3/9/2022 at 11:32 AM. Patient #5 Review of medical record revealed: The agency’s “Recertification/Follow-up Assessment” dated 7/22/2021 failed to provide evidence that of the patient’s strengths, limitations, and care preferences. These findings were confirmed with the Alternate Clinical Director on 3/9/2022 at 11:50 AM.

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 clinical record review, policy review and staff interview, it was determined that the agency failed to accurately identify medications patients are currently using in the comprehensive assessment for 3 of 7 patients (Patient #2, #4, #5) in the sample. Findings included: The agency policy entitled “Comprehensive Assessment” stated, “…The Comprehensive Assessment shall be updated and revised…in conformance with AHCA (At Home Care Agency) policy…every 60 days from start of care…the Comprehensive Assessment shall include the following information…a comprehensive review and history of prescribed…medications.” The agency policy entitled “Care Planning – Home Health” states, “…The Plan of Care shall include …medications, including dose, frequency, and route…” Patient #2 Review of Medical Record revealed: The “Home Health Certification and Plan of Care” for the period for the 7/22/2021 to 9/22/2021 certification period revealed a physician order for Iron Sulfate (FeSo4) 325 mg tabs (tablets) 1 tab PO (by mouth) twice daily. The “Medication Profile” dated 7/22/2021 revealed an entry for Iron Sulfate 325 mg 1 tab daily. There is no evidence the physician changed the order for Iron Sulfate 325 mg 1 tab PO to be given daily. This finding was confirmed with the Alternate Clinical Director on 3/9/2022 at 11:32 AM. Patient #4 Review of Medical Record revealed: The “Home Health Certification and Plan of Care” for the period for the 1/10/2022 to 3/11/2022 certification period revealed a physician order for Lorazepam 1 mg (milligram) 1 tab (tablet) PO (by mouth) every 8 hours PRN (as needed) anxiety. The “Medication Profile” dated 1/10/2022 revealed an entry for Lorazepam 1 mg PO 1 tab Q (every) 8 hours. There is no evidence the physician changed order for Lorazepam 1 mg PO to be given every 8 hours. An interview with Alternate Clinical Director on 3/9/2022 at 12:50 PM revealed “Nurse #2 states patient is receiving Lorazepam every 8 hours around the clock.” Findings that Patient #4 is receiving Lorazepam 1 mg every 8 hours routinely instead of as needed as ordered by physician was confirmed with Alternate Clinical Director on 3/9/2022 at 12:50 PM Patient #5 Review of Medical Record revealed: The “Home Health Certification and Plan of Care” for the period for the 1/16/2022 to 3/15/2022 certification period revealed a physician order for Acetaminophen (Tylenol) 325 mg 2 tablets PO (by mouth) every 4 hours. The “Medication Profile” dated 1/14/2022 revealed an entry for Tylenol 650 mg (2 tabs [tablets]) PO (by mouth) 2 tabs q (every) 4 hours. There is no evidence the physician changed the order to Acetaminophen (Tylenol) 650 mg 2 tablets PO q 4 hours. This finding was confirmed with the Alternate Clinical Director on 3/9/2022 at 12:04 PM.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and staff interview, it was determined that the agency failed to update the comprehensive assessment at discharge for 2 of 7 patients (Patients #1, #2) in the sample. Findings included: The agency policy entitled “Comprehensive Assessment” stated, “…The Comprehensive Assessment shall be updated and revised…at discharge…” The agency policy entitled “Clinical Record Contents” stated, “…A discharge summary is to be completed on all patients/clients discharged from the Agency. It is to be completed within 5 days of discharge.” The agency policy entitled “Medical Records: stated, “…Agency shall ensure that the medical record contains the following information…discharge/transfer summary…” Patient #1 Review of Medical Record revealed no evidence of an updated comprehensive discharge assessment or a completed discharge summary since patient’s discharge on 5/19/2021. This finding was confirmed by Alternate Clinical Director on 3/9/2022 at 10:28 AM. Patient #2 Review of Medical Record revealed no evidence of an updated comprehensive discharge assessment or a completed discharge summary since patient’s discharge on 9/14/2021. This finding was confirmed by Alternate Clinical Director on 3/9/2022 at 11:36 AM.

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 clinical record review, policy review and staff interview, it was determined that: for 7 of 7 patients (Patients #1, #2, #3, #4, #5, #6, #7) in the sample, the plan of care failed to include all the required components. Findings included: The agency policy entitled “Care Planning – Home Health” stated, “…The Plan of Care shall include at least the following information…Psychosocial status…Patient’s risk for emergency department visits and hospital re-admission…measurable…goals identified by AHCA (At Home Care Agency) and patient…advanced directives…” Patient #1 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 2/21/2021 – 4/22/2021 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 at 10:00 AM. Patient #2 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 7/22/2021 – 9/22/2021 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 at 10:00 AM. Patient #3 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 12/20/2021 – 2/18/2022 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 at 10:00 AM. Patient #4 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 1/10/2022 – 3/11/2022 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 between at 10:00 AM. The “Home Health Certification and Plan of Care” for the period 1/10/2022 – 3/11/2022 included the goal that “Patient will be able to manage self at home and return to an independent level of care by the end of the certification period.” The activities permitted indicated patient was complete bedrest and required transfer to the bed and chair. The functional limitations indicated patient with paralysis and ambulation limitation. Interview with daughter during my observation of a home visit on 3/3/2022 between 12:08 – 12:46 PM, it was revealed the patient is restricted to the bed, the chair, and a wheelchair and requires a Hoyer lift for transfers. Interview with the Alternate Clinical Director on 3/9/2022 between 10:10 – 10:20 AM revealed that the patient goal, “Patient will be able to manage self at home and return to an independent level of care by the end of the certification period,” is not a goal identified by the patient or family. This finding was confirmed by Alternate Clinical Director on 3/9/2022 between 10:10 – 10:20 AM that the goal of “Patient will be able to manage self at home and return to an independent level of care by the end of the certification period” was not a goal identified by patient or family. Patient #5 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 1/16/2022 – 3/15/2022 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 at 10:00 AM. Patient #6 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 11/21/2021 – 1/20/2022 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 at 10:00 AM. Patient #7 Review of medical record revealed: The “Home Health Certification and Plan of Care” for the period 12/21/2021 – 2/19/2022 failed to include the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admissions, and information related to any advanced directives. This finding was confirmed by Clinical Director and Alternate Clinical Director on 3/9/2022 at 10:00 AM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined that for 6 of 7 patients (Patient’s #1, #3, #4, #5, #6, #7) in the sample who received patient care services, the agency failed to ensure services were administered as ordered by the physician. Findings included: The agency policy entitled “Care Planning – Home Care” stated, “…All clinical services shall be implemented on in accordance with a plan of care established by a physician’s written orders...” The agency policy entitled “Physician/Allowed Practitioner Responsibilities” stated, “…Signed physician/allowed practitioner’s orders…are required for all services rendered by the agency…” The agency policy entitled “Care Plan Implementation and Missed Visits” stated, “…AHCA (At Home Care Agency) shall provide care, treatment and/or services…on the days and at the times scheduled with the patient/family…documentation of missed visits shall be done using the allocated missed visit form…” Patient #1 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 1/21/2021 to 4/22/2021 revealed physician order for 21 hours of HHA (Home Health Aide)/CNA (Certified Nurse Assistant) services per week for 9 weeks. The agency’s “Clear Care HHA Visit” documentation revealed patient did not receive HHA/CNA services on 3/18/2021, 3/19/2021, 3/22/2021, 3/23/2021, 3/25/2021, and 3/26/2021; patient cancelled visit scheduled on 3/24/2021. There is no evidence in medical record of the reason for missed visits. There is no evidence in medical record of attempts by the agency to schedule alternate care givers for missed visits. An interview with Alternate Clinical Director on 3/8/2022 at 11:40 AM revealed “Patient #1’s caregiver tested positive for COVID-19 and Patient #1 did not want another caregiver to provide care.” An alternate caregiver was scheduled for 3/24/2021 but “patient cancelled this visit.” The agency provided a word document (saved on the agency’s computer, not part of the medical record) with a narrative about the “reason for missed visits” for dates of service 3/18/2021 – 3/26/2021. Findings of missed visits, lack of documentation of missed visits in the medical record, and caregiver not completing the “On-Hold/Missed/Late/Resumption of Care Visit Report” confirmed with Alternate Clinical Director on 3/9/2022 at 10:25 AM. Patient #3 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 12/20/2021 to 2/18/2022 revealed a physician order for six PRN (as needed) SN (skilled nurse) visits. The agency’s “Nursing Visit Note” during the certification period of 12/20/2021 to 2/18/2022 revealed 9 skilled nursing visits were made during the certification period of 1/10/2022-3/11/2022; visits were made on 12/23/2021, 12/30/2021, 1/6/2022, 1/13/2022, 1/20/2022, 1/27/2022, 2/3/2022, 2/10/2022, and 2/17/2022. Findings that more than 6 skilled nurse visits were made during the certification period of 12/20/2021 to 2/18/2022 was confirmed with Clinical Director on 3/9/2022 at 10:20 AM. Patient #3 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 12/20/2021 to 2/18/2022 revealed physician order for 24 hours pf HHA (Home Health Aide)/CNA (Certified Nurse Assistant) services per week for 9 weeks. The agency’s “Clear Care HHA Visit” documentation revealed patient received 18 hours of HHA/CNA services for the week of 12/19/2021; visits were not made on 12/24/2021 and 12/25/2021. Patient received 0 hours of HHA/CNA services for the week of 12/26/2021; visits were not made from 12/27/21 to 1/1/2022. Patient received 12 hours of HHA/CNA services for the week of 1/9/2022; visits were not made from 1/12/2022 to 1/15/2022. Patient received 18 hours of HHA/CNA services for the week of 1/16/2022; visit was not made 1/17/2022. Patient received 20 hours of HHA/CNA services provided for the week of 1/23/2022; visit not made 1/29/2022. There is no evidence in medical record of the reason for missed visits. There is no evidence in medical record of attempts by the agency to schedule alternate care givers for missed visits. Findings of reduced weekly HHA/CNA services hours, missed visits, lack of documentation of missed visits in the medical record, and caregiver not completing the “On-Hold/Missed/Late/Resumption of Care Visit Report” confirmed with Clinical Director on 3/9/2022 at 10:12 AM. Patient #4 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 1/10/2022 to 3/11/2022 revealed a physician order for six PRN (as needed) SN (skilled nurse) visits. The agency’s “Nursing Visit Note” during the certification period of 1/10/2022 to 3/11/2022 revealed eight skilled nursing visits were made during the certification period of 1/10/2022-3/11/2022; visits were made on 1/12/2022, 2/19/2022, 1/26/2022, 2/2/2022, 2/9/2022, 2/16/2022, 2/23/2022, and 3/3/2022. Findings that more than 6 skilled nurse visits were made during the certification period of 1/10/2022 to 3/11/2022 confirmed with Alternate Clinical Director on 3/9/2022 at 9:57 AM. Patient #5 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 1/16/2022 to 3/15/2021 revealed physician order for 16 hours of HHA (Home Health Aide)/CNA (Certified Nurse Assistant) services per week for 9 weeks. The agency’s “Clear Care HHA Visit” documentation revealed patient did not receive HHA/CNA services on 1/17/2022 and 1/18/2022. There is no evidence in medical record of the reason for missed visits. There is no evidence in medical record of attempts by the agency to schedule alternate care givers for missed visits. Findings of missed visits, lack of documentation of missed visits in the medical record, and caregiver not completing the “On-Hold/Missed/Late/Resumption of Care Visit Report” confirmed with Alternate Clinical Director on 3/9/2022 at 11:50 AM. Patient #6 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 11/21/2021 to 1/20/2022 revealed physician order for 27 hours of HHA (Home Health Aide)/CNA (Certified Nurse Assistant) services per week for 9 weeks. The agency’s “Clear Care HHA Visit” documentation revealed patient received 36 hours of HHA/CNA services for the week of 11/21/2021. Patient received 36 hours of HHA/CNA services for the week of 11/28/2021. Patient received 36 hours of HHA/CNA services for the week of 12/5/2021. Patient received 36 of HHA/CNA services for the week of 12/12/2021. There is no evidence in the medical record the physician increased HHA/CNA services to 36 hours per week. Findings of increased weekly HHA/CNA services hours confirmed with Alternate Clinical Director on 3/9/2022 at 11:20 AM. Patient #7 Review of medical record revealed: The agency’s “Home Health Certification and Plan of Care” for certification period of 12/21/2021 to 2/19/2022 revealed physician order for 12 hours of HHA (Home Health Aide)/CNA (Certified Nurse Assistant) services per week for 9 weeks. The agency’s “Clear Care HHA Visit” documentation revealed patient received 6 hours of HHA/CNA services for the week of 12/26/2021; visits were not made on 12/28/2021 and 12/30/2021. Patient received 6 hours of HHA/CNA services for the week of 1/2/2022; all scheduled visits made. Patient received 6 hours of HHA/CNA services for the week of 1/9/2022; all scheduled visits made. Patient received 7 of HHA/CNA services for the week of 1/16/2022; all scheduled visits made. Patient received 6 hours of HHA/CNA services for the week of 1/23/2022; all scheduled visits made. Patient received 7 hours of HHA/CNA services for the week of 1/30/2022; all scheduled visits made. Patient received 7 hours of HHA/CNA services for the week of 2/6/2022; all scheduled visits made. Patient received 7 hours of HHA/CNA services for the week of 2/13/2022; all scheduled visits made. There is no evidence in medical record of the reason for missed visits. There is no evidence in medical record of attempts by the agency to schedule alternate care givers for missed visits. There is no evidence in the medical record the physician reduced HHA/CNA services to less than 12 hours per week. Findings of reduced weekly HHA/CNA services hours, missed visits, lack of documentation of missed visits in the medical record, and caregiver not completing the “On-Hold/Missed/Late/Resumption of Care Visit Report” confirmed with Clinical Director on 3/9/2022 at 10:33 AM.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on policy review and staff interview, it was determined that the agency did not include OASIS data in the process of their QAPI program or in the QAPI scope of activities. Findings included: The agency policy entitled “Organizational Quality Assessment and Performance Improvement (QAPI) Program” stated, “…Process design contains the following focus elements…Utilizes reports generated from OASIS data, including the following OASIS reports…AHCA’s (At Home Care Agency) QAPI activities shall: Focus on high risk volume or problem prone areas…Consider incidence, prevalence, and severity of problems in identified areas…” iQIES report titled “HHA List – No Successful Production Submissions Report” completed on 2/25/2022 indicated At Home Care Agency, CCN #087043, had no OASIS Submission and no Accepted OASIS Records for the date range 1/1/2021 – 12/31/2021. iQIES report titled “At Home Care Agency Potentially Avoidable Events” completed on 2/28/2022 revealed no results. Interview with Director on 3/1/2022 at 12:18 PM revealed that the agency has not submitted OASIS data since they lost JACHO (Joint Commission on Accreditation of Healthcare Organizations) accreditation in 2020. The Director states they are not billing Medicare but did state they are billing Delaware Medicaid. Confirmed findings with the Director on 3/1/2022 at 12:18 PM that the agency failed to electronically report all OASIS data collected in accordance with 484.55.

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, policy review and staff interview, it was determined that for 1 of 2 patients (Patient #3) observed during a home visit, the agency staff failed to adhere to accepted standards of practice regarding infection prevention and hand hygiene. Findings included: The agency policy entitled “Hand Hygiene – CDC Guidelines” stated, “…All staff shall use hand-hygiene techniques, as set forth in the following procedure…always after removing gloves or facemask…” On 3/3/22 between 10:05 AM and 10:41 AM, the following was observed during a home visit as RN #2 assessed Patient #3: performed hand hygiene donned gloved took patient’s temperature patient’s blood pressure cuff placed on patient cleaned stethoscope with Clorox wipe took patient’s blood pressure assessed patient’s heart, lungs, and bowel sounds with stethoscope assessed patient’s legs removed gloves donned new gloves cleaned supplies - stethoscope, blood pressure cuff, and thermometer removed gloves performed hand hygiene RN #2 failed to perform hand hygiene: after removal of gloves following patient assessment before donning new gloves to clean supplies On 3/3/22 at 10:57 AM RN #2 confirmed that they failed to adhere to accepted standards of practice regarding hand hygiene.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on review of agency documents, policies, and staff interview, it was determined that the agency failed to ensure that all staff are fully vaccinated for COVID-19. Findings included: The agency policy entitled “COVID-19 Final Rule – COVID-19 Staff Vaccination in Home Health” stated, “…All eligible staff must have received the necessary shots to be fully vaccinated…by (Phase II) February 27, 2022… Review of agency staff COVID-19 vaccine data for indicates that 37% of staff are not fully vaccinated. The agency employs 137 staff; 86 staff members are fully vaccinated for COVID-19, 1 staff member has received their 1st COVID-19 vaccine, 2 staff members have requested an exemption which are currently being, and 48 staff members COVID-19 vaccine status is unknown. These findings were confirmed with the Clinical Director on 3/9/2022 at 9:47 AM.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of agency policies, job descriptions, and personnel files, it was determined that the Administrator failed to ensure qualified personnel were employed for 3 of 3 employees (Chore Aide #1, RN #2, Chore Aide #2) sampled. Findings included: The agency policy entitled “Screening and Hiring” stated, “…the applicant is asked to bring …list of references…A service letter is required from the applicant’s current or most recent previous employer…For applicants who have not previously employed the Agency requires letters of reference from 2 adults who are familiar with the applicant, but who are not relatives…The applicant will also provide a signed and dated job description…all individuals must meet the minimum qualifications in accordance with applicable laws…” Chore Aide #1 Review of personnel file revealed: There was no evidence of the employee completing an annual TB (Tuberculosis) symptom questionnaire since completing TB baseline testing in 11/2019. There was no evidence the employees received an annual performance evaluation since date of hire, 12/26/2019. There is no evidence of pre-hire service letters being obtained. There is no evidence of a pre-hire State of Delaware Adult Abuse Registry clearance being completed. These findings were confirmed with the Clinical Director on 3/9/2022 at 11:18 AM. RN #2 Review of personnel file revealed: There is no evidence of a letter of appointment or signed job description provided at time of hire. There is no evidence of pre-hire service letters being obtained. These findings were confirmed with the Clinical Director on 3/9/2022 at 11:29 AM. Chore Aids #2 Review of personnel file revealed: There was no evidence the employees received an annual performance evaluation since date of hire, 3/13/2020. There is no evidence of pre-hire service letters being obtained. There is no evidence of a pre-hire State of Delaware Adult Abuse Registry clearance being completed. These findings were confirmed with the Clinical Director om 3/9/2022 at 10:54 AM.

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: Based on clinical record review, policy review, and staff interview, it was determined that for 3 of 7 patients (Patient’s #1, #2, #3) in the sample who received patient care services, the agency failed to ensure all interventions, including services, were included in the clinical record. Findings included: The agency policy entitled “Clinical Record Contents” stated, “…The clinical record contains the following information…Aide Activity Report…The aide is to check off those services implemented…The aide notes will include the dates of service, hours of service, type of service provided…” The agency policy entitled “Medical Records” stated, “…AHCA shall ensure that the medical record contains the following information…there shall be documentation of all interventions/services provided… The agency policy entitled “Late Entries to the Electronic Health Record” stated, “…AHCA staff shall make every attempt to document in the medical record in a timely manner. If an entry in the medical record is missed or not written, the staff member may enter a late entry into the medical record. The late entry must be documented as soon as possible.” Patient #1 Review of medical record revealed: The agency’s “Clear Care HHA Visit” documentation revealed Home Health Aide made visits on 3/4/2021 and 3/8/2021 without documenting services provided or hours of service. This finding was confirmed with Alternate Clinical Director on 3/3/2022 at 9:50 AM. The agency’s “Supervisory Visit Form” documentation revealed no evidence the Aide’s performance was evaluated during supervisory visits on 3/22/2021 and 4/19/2021. This finding was confirmed with the Alternate Clinical Director on 3/9/2022 at 10:35 AM. Patient #2 Review of medical record revealed: The agency’s “Clear Care HHA Visit” documentation revealed Home Health Aide made visits on 7/22/2021, 7/23/2021, 7/26 – 7/30/21, 8/2 – 8/6/2021, 8/9 – 8/13/2021, 8/16 – 8/21/2021, 8/23 – 8/27/2021, 8/30 – 9/4/ 2021, 9/6 – 9/10/2021, and 9/13 – 9/14/2021 without documenting services provided or hours of service. This finding was confirmed with the Clinical Director on 3/9/2022 at 11:43 AM. Patient #3 Review of medical record revealed: The agency’s “Clear Care HHA Visit” documentation revealed Home Health Aide made visits on 1/9/2022 and 1/10/2022 without documenting services provided or hours of service. This finding was confirmed with the Clinical Director on 3/9/2022 at 10:12 AM.