Every finding on record at At Peace Health Care Agency LLC

Based on the findings of an onsite unannounced Medicare recertification and state re-licensure survey conducted June 23, 2021, June 24, 2021, and off-site on June 25, 2021, June 28, 2021, and June 30, 2021, At Peace Health Care Agency, 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 and state re-licensure survey conducted June 23, 2021, June 24, 2021, and off-site on June 25, 2021, June 28, 2021, and June 30, 2021, At Peace Health Care Agency, LLC was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records (CR), agency documentation, and interview with the administrator, it was determined that the agency failed to ensure physician ' s orders were followed for Physical Therapy (PT) visits for two (2) of four (4) discharged clinical records (CR) reviewed (CR #2 and #4). Agency also failed to ensure clinical records included physician ' s orders for all Skilled Nursing (SN) visits for two (2) of four (4) discharged clinical records (CR) reviewed (CR #2 and #4). Findings include: A review of clinical records conducted on June 24, 2021, at approximately 10:30AM, revealed the following: CR #2, Start of Care 10/27/2019. Certification period 10/27/2019 through 12/25/2019 and Discharged on 12/23/2019. Contained orders for Skilled Nursing (SN): Three (3) visits per week for two (2) weeks, then two (2) visits per week for four (4) weeks, then one (1) visit per week for one (1) week, and Physical Therapy (PT): One (1) to two (2) visits per week for nine (9) weeks (effective 11/1/2019). Review of PT visit documentation on 6/24/2021 at approximately 10:45AM, and off-site on June 30, 2021 at approximately 9:00AM, revealed visits were made during week #1 through week #4 (11/1/2019 - 11/21/2019) as ordered, except on 11/7/2019 and 11/12/2019). PT visit documentation did not show scheduled visits for week #5 through week #8 (11/24/2019 - 12/21/2019). Missed visit notes were documented for 11/7/2019 and 11/12/2019. However, there was no documentation of missed visits during week #5 through week #8 (11/24/2019 - 12/21/2019), nor was there documentation that physician was notified. Review of SN visit documentation on 6/24/2021 at approximately 10:55AM, and off-site on June 30, 2021 at approximately 10:00AM, revealed visits were made during week #1 through week #7 (10/27/2019 - 12/23/2019) as ordered, for a total of fifteen (15) visits. However, three (3) additional SN visits were made on 12/12/2019, 12/17/2019, and 12/19/2019. There were no new physician ' s orders in clinical record to validate these three (3) additional SN visits. CR #4, Start of Care 12/17/2018. Certification period 4/16/2019 through 6/14/2019; 6/15/2019 - 8/13/2019 and Discharged on 6/21/2019. Contained orders for Skilled Nursing (SN): One (1) visit per week for four (4) weeks, and Physical Therapy (PT): Two (2) visits per week for nine (9) weeks. Review of PT visit documentation on 6/24/2021 at approximately 11:15AM, and off-site on June 30, 2021 at approximately 9:20AM, revealed visits were made during week #1 through week #3 (4/14/2019 - 5/4/2019 as ordered, except visit #2 was not made during week #1 (4/14/2019 - 4/20/2019). PT visit documentation did not show scheduled visits for week #4 (5/5/2019 - 5/11/2019) and visit #2 was not made during week #5 (5/12/2019 - 5/18/2019). There was no documentation of missed visits nor was there documentation that physician was notified. Review of SN visit documentation on 6/24/2021 at approximately 11:30AM, and off-site on June 30, 2021 at approximately 10:20AM, revealed SN visits were made on 4/18/2019, 4/25/2019, 5/13/2019, and 5/20/2019. However, three (3) additional SN visits were made on 5/17/2019, 5/23/2019, and 5/28/2019. There were no new physician ' s orders in clinical record to validate these three (3) additional SN visits. Interview with administrator on 6/24/2021 at 2:45PM confirmed the above findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), agency documentation, and interview with the administrator, it was determined that the agency failed to ensure skilled visits were scheduled for Physical Therapy (PT) for two (2) of four (4) discharged clinical records (CR) reviewed (CR #2 and #4). Agency also failed to ensure clinical records included physician ' s orders for all Skilled Nursing (SN) visits for two (2) of four (4) discharged clinical records (CR) reviewed (CR #2 and #4). Findings include: A review of clinical records conducted on June 24, 2021, at approximately 10:30AM, revealed the following: CR #2, Start of Care 10/27/2019. Certification period 10/27/2019 through 12/25/2019 and Discharged on 12/23/2019. Contained orders for Contained orders for Skilled Nursing (SN): Three (3) visits per week for two (2) weeks, then two (2) visits per week for four (4) weeks, then one (1) visit per week for one (1) week, and Physical Therapy (PT): One (1) to two (2) visits per week for nine (9) weeks (effective 11/1/2019). Review of PT visit documentation on 6/24/2021 at approximately 10:45AM, and off-site on June 30, 2021 at approximately 9:30AM, revealed visits were not scheduled during week #5 through week #8 (11/24/2019 - 12/21/2019). There was no documentation in clinical record that physician was notified that visits were not scheduled. Review of SN visit documentation on 6/24/2021 at approximately 10:55AM, and off-site on June 30, 2021 at approximately 10:00AM, revealed visits were made during week #1 through week #7 (10/27/2019 - 12/23/2019) as ordered, for a total of fifteen (15) visits. However, three (3) additional SN visits were made on 12/12/2019, 12/17/2019, and 12/19/2019. There were no new physician ' s orders in clinical record to validate these three (3) additional SN visits. CR #4, Start of Care 12/17/2018. Certification period 4/16/2019 through 6/14/2019; 6/15/2019 - 8/13/2019 and Discharged on 6/21/2019. Contained orders for Skilled Nursing (SN): One (1) visit per week for four (4) weeks, and Physical Therapy (PT): Two (2) visits per week for nine (9) weeks. Review of PT visit documentation on 6/24/2021 at approximately 11:15AM, and off-site on June 30, 2021 at approximately 9:45AM, revealed visits were not scheduled during week #4 (5/5/2019 - 5/11/2019), and visit #2 was not scheduled during week #5 (5/12/2019 - 5/18/2019). There was no documentation in clinical record that physician was notified that visits were not scheduled. Review of SN visit documentation on 6/24/2021 at approximately 11:30AM, and off-site on June 30, 2021 at approximately 10:20AM, revealed SN visits were made on 4/18/2019, 4/25/2019, 5/13/2019, and 5/20/2019. However, three (3) additional SN visits were made on 5/17/2019, 5/23/2019, and 5/28/2019. There were no new physician ' s orders in clinical record to validate these three (3) additional SN visits Interview with administrator on 6/24/2021 at 2:45PM confirmed the above findings.