Every finding on record at At Home Nursing and Therapy Services LLC

Based on the findings of an onsite unannounced Medicare recertification survey completed August 25, 2023, At Home Nursing and Therapy Services Llc was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification survey completed August 25, 2023, At Home Nursing and Therapy Services Llc was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of agency policy, clinical records (CR), observation during home visits (HV), and staff (EMP) interview, the agency failed to ensure all of the patient's medications were included on the plan of care for three (3) of 15 active records reviewed (CR2, CR13, & CR14). Findings included: Review of agency policy on August 25, 2023, at 1:30 p.m. showed, "PHYSICIAN'S PLAN OF CARE/ CHANGE ORDERS Revised: July 10, 2020 POLICY: ... The Plan of Care shall include but not limited to: ... Medications." Review of CR2 on August 23, 2023, at 8 a.m. showed a physician ordered plan of care beginning 7/3/2023 for an initial certification period ending 8/31/2023. PT was the only discipline ordered to see the patient once per week. During a 7/10/2023 PT visit, the therapist documented, "Patient reports increased tremors in UE's limiting his ability to complete ADL's. He reports he is contacting his neurologist about this for change in medication." No physician contact concerning dizziness or the need for a medication change. During the 7/18/2023 PT visit, the PT documented, "[Patient] reports increased dizziness due to new medication." Interview with EMP1 on August 25, 2023, at 12:36 p.m. confirmed findings and that the above medication change did not appear on CR2's plan of care, "not sure what the medication was." Review of CR13 during a visit to patient's home on August 24, 2023, at 11:30 a.m. revealed a physician ordered plan of care beginning on 8/17/2023 for an initial certification period ending 10/15/2023. Nursing was to see the patient three times per week for care and assessment. Surveyor reviewed the patient's medications with him and EMP1 at 11:51 a.m. The review revealed the patient is taking Tylenol "sometimes for pain," a stool softener Docusate 100mg daily, a multivitamin daily, and calcium 600mg daily. EMP1 confirmed the medications were not listed on CR13's plan of care. Review of CR14 on August 23, 2023, at 1:15 p.m. showed a physician ordered plan of care beginning 7/6/2023 for an initial certification period ending 9/3/2023. SN was ordered to see the patient twice a week for care and assessment. On 8/2/2023, the RN documented, "CG [caregiver] spouse reports dizziness intermittently throughout day. Cg had called PCP [attending] who told her to call cardiologist on 7/28 to report low b/p [blood pressure]. cg is retired RN and keeps track of b/p status and logs all. RN called cardiologist and message left on RN line with BP readings, med list, c/o dizziness. Waiting on return call. During subsequent SN visit on 8/7/2023, the nurse documented, "Cardiologist made some changes due to low b/p reading. RN and cg will continue to monitor." On 8/10/2023, the SN documented that patient's cardiologist made medication changes effective 8/4/2023, "Md discontinued ... amidarone [sic] and changed lasix dose to QOD [every other day] effective 8/4/2023. At 1:27 p.m., EMP1 reviewed CR14 and confirmed that the patient's medication list still contained amiodarone (not discontinued), and the lasix dose was not changed to QOD as ordered.

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 review of agency policy and procedure, clinical records (CR), and staff (EMP) interview, the agency failed to promptly notify the physician 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 for eight (8) of 17 records reviewed (CR1-CR4, CR6, CR9, CR11, & CR14). Findings included: Review of agency policy on August 25, 2023, at 1:30 p.m. showed, "PHYSICIAN'S PLAN OF CARE/ CHANGE ORDERS Revised: July 10, 2020 POLICY: ... Verbal Change Orders ... The physician shall be notified immediately of any changes in the patient's condition that indicate changes to the Plan of Care." Review of CR1 on August 22, 2023, at 2 p.m. showed a physician ordered plan of care beginning 8/12/2023 for an initial certification period ending 10/10/2023. Physical therapy (PT) was the only discipline ordered to see the patient two times per week. During the 8/14 PT visit, the therapist documented, "[Patient] reports dizziness with position change. ... patient with reported appointment on Wednesday 816 [8/16] 2023 PT encouraged patient and daughter to request compression stockings to help with blood pressure with position change." CR1 did not show the physician was notified concerning the patient's dizziness or patient's need for compression stockings. Review of CR2 on August 23, 2023, at 8 a.m. showed a physician ordered plan of care beginning 7/3/2023 for an initial certification period ending 8/31/2023. PT was the only discipline ordered to see the patient once per week. During a 7/10/2023 PT visit, the therapist documented, "Patient reports increased tremors in UE's limiting his ability to complete ADL's. He reports he is contacting his neurologist about this for change in medication." No physician contact concerning increased tremors or the need for a medication change. During the 7/18/2023 PT visit, the PT documented, "[Patient] reports increased dizziness due to new medication." No physician contact concerning increased dizziness. There was nothing in the record to show what patient's new medication was. During the 8/15/2023 PT visit, the PT documented, "[patient] reports accidentally taking too much medication but is unsure which one resulted in him falling when he got home." No physician contact concerning the patient's medication error. Review of CR3 on August 22, 2023, at 2:30 p.m. showed a physician ordered plan of care beginning 8/2/2023 for an initial certification period ending 9/30/2023. Skilled nursing (SN) was ordered to see the patient twice a week. During the 8/14/2023 SN visit, the nurse documented, "patient has been vomiting all night. Patient states he is not able to eat and go to the bathroom, he is not able to sit on the couch, only able to lay down. ... low O2 [oxygen saturation]. Patient not able to sit up for assessment. RN called patients [sic] daughter and agreeable to 911 to be called. Medics came and assessed patient and took him to [Hospital]." CR3 did not show patient's attending physician was notified of patient's change in condition: vomiting, low oxygen level, and his trip to the emergency room. Review of CR4 on August 23, 2023, at 8 a.m. showed a physician ordered plan of care beginning 7/21/2023 for an initial certification period ending 9/18/2023. PT was the only discipline ordered to see the patient twice a week, and to notify the physician for pain greater than 5 (0-10 scale with 10 being worse). During the 7/24/2023 PT visit, the PT documented," [Patient] reports still puzzled about left LE [lower leg] swelling and is awaiting a call from physician." The PT also documented the patient rated his pain at 7. A review of CR4's start of care completed on 7/21/2023 by a PT did not show that patient suffered from LE edema. No physician notification concerning patient's edema or pain. Review of CR6 on August 23, 2023, at 10 a.m. showed a physician ordered plan of care beginning 7/26/2023 for an initial certification period ending 9/3/2023. PT was the only discipline ordered to see the patient twice a week. During the 8/11/2023 PT visit, the PT documented, "[Patient] continues to note bilat [both] LE discomfort with prolonged mobility ... PT recommended contacting [patient to do] MD/medical team if LEs continue to worsen and for further management, [daughter] and patient verbally receptive. During subsequent 8/16/2023 PT visit, the patient was sent to the ER due to increased pain and weakness. CR3 did not show that the PT contacted the patient's change in condition on 8/11/2023. Review of CR9 on August 23, 2023, at 11 a.m. showed a physician ordered plan of care beginning 3/8/2023 for an initial certification period ending 5/6/2023. PT was the only discipline ordered to see the patient twice a week. During the 3/9/2023 PT visit, the PT documented, "In standing ex [exercise] at sink with [patient]. Complains of nausea with attempts at vomiting unsuccessful. [Patient] requested return to bed due to nausea. ... Advised [patient], husband and daughter that if nausea and vomiting continues into tomorrow, to call physician." On 3/13/2023 visit, the PT documented that the patient was unable to take her medications due to nausea. On 3/15/2023 visit, the PT documented that patient was up all night after the 3/13/2023 visit and could not sleep due to increased pain. During the 3/20/2023 PT visit, the PT documented, "[Patient reports difficulty sleeping and waiting for a call from PCP [attending physician] for a sleeping pill. CR9 did not show that the PT contacted the patient's attending physician since the 3/9 (10 days) findings concerning the patient's nausea and difficulty sleeping at night related to increased pain. Review of CR11 on August 23, 2023, at 11:45 a.m. showed a physician ordered plan of care with a recertification period from 8/17/2023 to 10/15/2023. SN was ordered to see the patient twice a week. On 8/21/2023, the SN documented, "Patient had a fall yesterday 8/20/2023 and has sutures ot [sic] his forehead that are unable to bee [sic] seen due to secure dressing over place and has 5 steristrips to right arm." CR11 did not show that SN contacted the physician concerning patient's fall and his new injuries. Review of CR14 on August 23, 2023, at 1:15 p.m. showed a physician ordered plan of care beginning 7/6/2023 for an initial certification period ending 9/3/2023. SN was ordered to see the patient twice a week for care and assessment. On 8/2/2023, the RN documented, "CG [caregiver] spouse reports dizziness intermittently throughout day. Cg had called PCP [attending] who told her to call cardiologist on 7/28 to report low b/p [blood pressure]. cg is retired RN and keeps track of b/p status and logs all. RN called cardiologist and message left on RN line with BP readings, med list, c/o dizziness. Waiting on return call. During subsequent SN visit on 8/7/2023, the nurse documented, "Cardiologist made some changes due to low b/p reading. RN and cg will continue to monitor." On 8/10/2023, the SN documented that patient's cardiologist made medication changes effective 8/4/2023. There was nothing to show SN contacted the patient's attending concerning medication changes. The above records were reviewed with EMP1 (administrator) and EMP3 (director of nursing) on August 25, 2023, from 12:30 p.m. to 2 p.m., and EMP1 and EMP3 confirmed above findings.

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 review of clinical records, and staff (EMP) interview, the agency failed to coordinate care with all physicians for two (2) of 15 active records reviewed (CR2, & CR14). Findings included: Review of CR2 on August 23, 2023, at 8 a.m. showed a physician ordered plan of care beginning 7/3/2023 for an initial certification period ending 8/31/2023. PT was the only discipline ordered to see the patient once per week. During a 7/10/2023 PT visit, the therapist documented, "Patient reports increased tremors in UE's limiting his ability to complete ADL's. He reports he is contacting his neurologist [not the attending/admitting physician] about this for change in medication." No physician contact concerning dizziness or the need for a medication change. During the 7/18/2023 PT visit, the PT documented, "[Patient] reports increased dizziness due to new medication." No physician contact concerning increased dizziness. There was nothing in the record to show what the patient's new medication was. During the 8/15/2023 PT visit, the PT documented, "[patient] reports accidentally taking too much medication but is unsure which one resulted in him falling when he got home." There was nothing to show that the therapist coordinated the patient's care with the attending physician or the neurologist concerning the patient's symptoms and medication change. Review of CR14 on August 23, 2023, at 1:15 p.m. showed a physician ordered plan of care beginning 7/6/2023 for an initial certification period ending 9/3/2023. SN was ordered to see the patient twice a week for care and assessment. On 8/2/2023, the RN documented, "CG [caregiver] spouse reports dizziness intermittently throughout day. Cg had called PCP [attending] who told her to call cardiologist on 7/28 to report low b/p [blood pressure]. cg is retired RN and keeps track of b/p status and logs all. RN called cardiologist and message left on RN line with BP readings, med list, c/o dizziness. Waiting on return call. During subsequent SN visit on 8/7/2023, the nurse documented, "Cardiologist made some changes due to low b/p reading. RN and cg will continue to monitor." On 8/10/2023, the SN documented that patient's cardiologist made medication changes effective 8/4/2023. There was nothing to show that the nurse coordinated the patient's care with the attending physician or the cardiologist concerning the patient's symptoms and medication change. The above records were reviewed with EMP1 (administrator) and EMP3 (director of nursing) on August 25, 2023, from 12:30 p.m. to 2 p.m., and EMP1 and EMP3 confirmed above findings.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), agency policy, and staff (EMP) interview, the nurse failed to ensure ongoing interdisciplinary assessment for two (2) of two (2) patients (CR14, & CR17) with peripherally inserted central catheters. Findings included: Review of agency policy on August 25, 2023, at 2 p.m. showed, "CENTRAL VENOUS CATHETER: SITE CARE ... SUMMARY This skill describes how to perform central venous catheter site care, including assessment, dressing, add-on devices and administration set changes. ... OVERVIEW ... CVCs in the home setting are typically used for administration of medications, such as antibiotics ... The most common CVC in home health is a peripherally central catheter (PICC). ... Procedure ... 12. Remove and discard the CVC dressing ... 13. Inspect the catheter, insertion site and surrounding skin ... 18. Cleanse the insertion site ... 21. Measure the external length of the CVC. If the external length of the catheter has changed, continue dressing and then call practitioner. Rationale: A change in external catheter length is an indicator of catheter movement. The tip may no longer be in the superior vena cava or inferior vena cava." Review of CR13 on August 23, 2023, at 12:50 p.m. showed a physician ordered plan of care beginning 8/17/2023 for an initial certification period ending 10/15/2023. Skilled nursing (SN) was to see the patient twice a week for care and assessment to include PICC care, "Perform PICC care dressing change weekly." Review of SN note from 8/14/2023 showed the nurse changed the patient's PICC dressing but failed to document the PICC's external catheter length. Review of CR17 on August 23, 2023, at 3:15 p.m. showed a physician ordered plan of care beginning 8/12/2023 for an initial certification period ending 10/10/2023. SN was to see the patient three times per week for care and assessment to include PICC care, "SN to change PICC line dressing, extension tubing, and stat lock once weekly under sterile technique." Review of SN note from 8/21/2023 showed the nurse changed the patient's PICC dressing but failed to document the PICC's external catheter length. The above records were reviewed with EMP1 (administrator) and EMP3 (director of nursing) on August 25, 2023, from 12:30 p.m. to 2 p.m., and EMP1 and EMP3 confirmed above findings.

Based on the findings of an onsite unannounced complaint investigation completed November 10, 2021, At Home Nursing and Therapy Services Llc was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on review of agency policy, a clinical record (CR), and staff (EMP) interview, the agency failed to arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities for one (1) of one (1) clinical record who was discharged (CR1). Review of agency policy on November 10, 2021, at 11 a.m. showed, "1.41 CLIENT BILL OF RIGHTS ... THE PATIENT HAS THE RIGHT: ... 27. To be referred to another agency if he/she is dissatisfied with the agency or the agency cannot meet the patient's needs." Review of CR1 on November 10, 2021, at 09:30 a.m. revealed a physician ordered plan of care beginning 9/3/2021 for an initial certification period ending 11/01/2021. Orders included skilled nursing 3 times per week for wound care. On 10/17/2021 the patient requested different hours outside of agency's usual operating hours and beyond the capabilities of the agency due to staffing and other patient needs. A coordination note made on 10/17/2017 showed, "Patient contacted writer after hours requesting his visits be completed prior to 7 AM or after 430 PM due to his starting a new job. Writer educated patient that those hours may not be able to accommodate [sic] as some patients require early and late visits for medical reasons and those time slots are reserved for patients, not patients who have chosen to go back to work, patient advised to contact his prescribing physician to see if there was another arrangement that could be made to accommodate patients [sic] request as our company was unable to guarantee visits with those time slots. Patient verbalized understanding to writer." A coordination note made on 10/18/2021 showed, "After patient finally returned call, he was advised that home health is not able to accommodate his work schedule after hours, as well as homebound status issue. Patient became agitated and belligerent stating "you have to come when I am available" Home health process was again explained to patient and he needs to contact his MD and insurance provider to see what other options are available. Patient again became agitated and said "I am done, you are a joke, I AM CALLING MY INSURANCE COMPANY" and hung up. Telephone call place to managing MD office [...] at 317pm with return call at 343pm Spoke with nursing staff over issue with the patient and that he was done with our services and that patient was advised to contact MD. Resolution/Follow Up: MD notified, patient discharged from services as per his demands." A coordination note from 10/21/2021 showed, "On 10/20/21, The write [sic] [EMP2 administrator] was present in office along with [EMP1] and [EMP4 nurse], when the patient called [EMP1]'s cell phone. The patient was placed on speaker phone so that I (the agency administrator) could be part of the conversation as well. The patient inquired as to why a nurse has not been out to do his wound vac yet. He was reminded about the previous 3 contacts, and immediately became defensive and stated that it did not happen. He stated that it was a 'misunderstanding and he was in a bad mood'. The patient did however reiterate that he must be seen before 8:00am or after 4:00pm. he was reminded that we cannot accommodate this request, and was notified that he was instructed to find a different agency. The patient was advised that he has been discharged from our agency and no further care could be provided by this agency." An interview with EMP1 and a phone interview with EMP2 on November 10, 2021, at 10:30 a.m. confirmed above findings and that agency discharged patient on 10/18/2021 but did not arrange for a safe and appropriate transfer to another home health agency.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on review of a clinical record (CR), and staff (EMP) interview, the agency failed to send a discharge/transfer summary containing all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effectie transition of care for one (1) of one (1) clinical records (CR1). Review of CR1 on November 10, 2021, at 09:30 a.m. revealed a physician ordered plan of care beginning 9/3/2021 for an initial certification period ending 11/01/2021. Orders included skilled nursing 3 times per week for wound care. On 10/17/2021 the patient requested different hours outside of agency's usual operating hours and beyond the capabilities of the agency due to staffing and other patient needs. Further review of CR1 showed patient and agency could not agree on the continuation of services. The agency discharged the patient on 10/18/2021. The clinical record did not show that the agency sent a discharge summary to the patient's physician or a transfer summary to the receiving agency that contained all necessary medical information. An interview with EMP1 and a phone interview with EMP2 on November 10, 2021, at 10:30 a.m. confirmed above findings and that agency discharged patient on 10/18/2021. EMP1 confirmed that agency did not send a discharge summary to the patient's physician or a transfer summary to the receiving agency that contained all necessary medical information.

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 review of a clinical record (CR), and staff (EMP) interview, the agency failed to ensure the clincial record contained a discharge summary sent to the primary care practitioner and the receiving home health agency when the patient required continued home health services for one (1) of one (1) clinical who was discharged from the agency but required continued services for wound care (CR1). Review of CR1 on November 10, 2021, at 09:30 a.m. revealed a physician ordered plan of care beginning 9/3/2021 for an initial certification period ending 11/01/2021. Orders included skilled nursing 3 times per week for wound care. On 10/17/2021 the patient requested different hours outside of agency's usual operating hours and beyond the capabilities of the agency due to staffing and other patient needs. Further review of CR1 showed patient and agency could not agree on the continuation of services. The agency discharged the patient on 10/18/2021. The clinical record did not show that the agency sent a discharge summary to the patient's physician or a transfer summary to the receiving agency since patient required continued home health services for wound care. An interview with EMP1 and a phone interview with EMP2 on November 10, 2021, at 10:30 a.m. confirmed above findings. EMP1 reviewed CR1 with surveyor and confirmed that it did not contain a discharge summary sent to the patient's physician or a transfer summary to the receiving agency.