Every finding on record at Atrium Healthcare Services, LLC

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 4/25/24. The facility was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted was conducted in conjunction with the evaluation of the Emergency Preparedness requirements on 4/25/24. Standard level deficiencies cited. Abbreviations: Pt./Pts. - Patient/Patients E - Employee POC - Plan of Care PsOC - Plans of Care AM - morning PM - afternoon/evening SOC - Start of Care

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical records review, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide information regarding the Administrator. Findings include: 1. The Pt. admission folder was reviewed on 4/22/24. The folder lacked documentation identifying the Administrator's name, and information for contacting the Administrator. 2. The following home visits were conducted on 4/22/24 and 4/23/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. During the home visits, the Pt. admission folders were observed, and lacked the Administrator's name, and information for contacting the Administrator. 3. The following clinical records were reviewed on 2/23/24 and 2/24/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. Pt. #4. SOC 1/27/24. Pt. #5. SOC 3/8/24. Pt. #6. SOC 2/8/24. Pt. #7. SOC 12/28/23. The records lacked documentation the Agency had provided the Administrator's name, and information for contacting the Administrator. 4. During an interview with the Director of Nursing on 4/24/24 from 10:22 AM to 1:06PM, the Director of Nursing confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide information regarding the Administrator.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical records review, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline. Findings: 1. The Pt. admission folder was reviewed on 4/22/24 and contained the form titled, "IN-HOME CALENDAR". The Agency required each discipline to enter their name and the frequency of visits on the form. 2. Home visits were conducted on the following Pts. on 4/22/24 and 4/23/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. During the home visits, the Pt. admission folders were observed, and lacked documentation that staff included the visit frequency for each discipline providing service. 3. The following clinical records were reviewed on 4/23/24 and 4/24/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. Pt. #4. SOC 1/27/24. Pt. #5. SOC 3/8/24. Pt. #6. SOC 2/8/24. Pt. #7. SOC 12/28/23. The records lacked documentation the Agency had provided in writing, the visit frequency for each discipline providing service. 4. During interviews with the Director of Nursing on 4/24/24 between 10:22 AM and 1:06 PM, the Director confirmed the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline.

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 observation and interviews during a home visit, clinical record review and staff interviews, it was determined that for 1 of 3 Pts. (Pt. #3) receiving Physical Therapy services, the Agency failed to ensure that the PsOC included all the equipment. Findings include: 1. Pt. #3 was admitted on 3/15/24 for home health services with the diagnoses of, but not limited to Muscle Weakness, Difficulty in Walking and Osteoarthritis of Knee, Unspecified. A home visit was conducted with E#2 (Physical Therapist) on 4/23/24 at 11:00 AM. During the visit, Pt. #3 was wearing bilateral knee braces, and these were removed by E#2 while providing therapy exercises for Pt. #3. E#2 stated that the bilateral knee braces were supplied as requested by the Physician and is being continuously used by Pt. #3 as support for transferring and walking. Pt. #3 was interviewed during the home visit and stated that the braces are used all the time “they support my knees.” Pt. #3’s clinical record was reviewed on 4/24/24. The initial POC effective 3/15/24, and the Physical Therapy POC dated 3/15/24 lacked documentation for the use of the bilateral knee braces, and interventions for its use. 2. During an interview conducted with the Director of Nursing on 4/24/24 at 12:00 PM, the above findings were confirmed.

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 clinical records review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge/Transfer Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6 was admitted for home health services on 12/28/23 with a primary diagnosis of Type 2 Diabetes Mellitus with unspecified complications. The record contained a transfer assessment, indicating that Pt. #6 was transferred to an in-patient facility on 1/9/24. As of 4/23/24, the record lacked documentation that a copy of Pt. #6’s transfer summary was sent to the Physician. 2. Pt. #7 was admitted for home health services on 2/28/24 with a primary diagnosis of Acute Systolic (Congestive) Heart Failure. The record contained a discharge assessment dated 4/1/24, indicating that Pt. #7 was discharged from the Agency. As of 4/24/24, the record lacked documentation that a copy of Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Director of Nursing on 4/24/24 at 12:00 PM, the above findings were confirmed.

. Recertification survey completed. Standard Level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 4/30/20. The Atrium Healthcare Services, LLC. was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: RN= Registered Nurse SN- Skilled Nurse Pt/Pts= Patient/Patients SOC= Start of care AM= morning PM= evening mg = milligram

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: . A. Based on home visit observation/ interviews, clinical records review, Agency's policy review and staff interview, it was determined that the Agency failed to ensure that patients' medication profile was accurate and complete. This was found in 1 of 3 (Patient #3) home visits conducted. Findings include: 1. Pt. #3 SOC: 7/12/19. Diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Hypertensive Heart disease with Heart Failure. A home visit was conducted on 4/28/21 at 10:00 AM with Physical Therapist. During the home visit observation and review of medications, the Patient's daughter presented medications which included bottles of "Hydrophilic top cream, Aspirin 81 mg and Multivitamins." Patient's daughter stated that patient has been taking these medications since last Veterans visit and visiting nurse is aware since she prefills the medication boxes". The clinical record of Pt #3 was reviewed on 4/28/21 at 9:00 AM and 11:00 AM. The record contained a Medication profile for episode of 3/3/21 to 5/1/21 and lacked the above medications on "Active Medications" list. There were no subsequent Physician's orders during this certification period for any new/medication changes. 2. The Agency's policy titled "Medication Profile" was reviewed on 4/29/21 at 1:35 PM and documented "....The medication profile shall include all prescription and over-the-counter medications. The profile will be updated as needed to reflect current medications the client is taking." 3. During interview with Administrator and Director of Nursing on 4/29/21 at 11:30 AM, the Director of Nursing stated the nurse should review medications on every visit and updated on the medication list and/or physician order. The Director of Nursing confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were assessed for the status of the influenza and/or pneumococcal vaccine at the (SOC) Start of Care per Agency policy. This was found in 4 of 7 (Pts. #2, 5, 1 and 3) clinical records reviewed. Findings include: 1. Pt #2 SOC: 07/18/20 Diagnosis: Primary Colon cancer. The clinical record of Pt #2 was reviewed on 04/27/21 at 1:00 PM. The record lacked documentation of the Influenza and Pneumococcal vaccination status. 2. Pt #5 SOC: 10/02/20 Diagnosis: Primary Hip fracture. The clinical record of Pt #5 was reviewed on 04/28/21 at 11:00 AM. The record lacked documentation of the Influenza and Pneumococcal vaccination status. 3. Pt #1 SOC 7/20/20. Diagnosis: Hypertension. The clinical record of Pt #1 was reviewed on 4/27/21 at 12:45 PM. The record included SOC comprehensive assessment dated 7/20/20 completed by the RN. The record lacked documentation of Influenza and Pneumococcal vaccination status. 4. Pt #3 SOC 7/12/19. Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The clinical record of Pt #3 was reviewed on 4/28/21 at 9:00 AM and 11:00 AM. The record included SOC comprehensive assessment dated 7/12/19 completed by the RN. The record lacked documentation of Influenza and Pneumococcal vaccination status. 5. The Agency's policy titled "Vaccinations" documents: "1. Upon initiation of home health services, the admitting clinician will complete an assessment to determine the patient's influenza and pneumococcal vaccination status ...3. The clinician will document the findings and follow-up activities in the patient record." 6. During interview with Administrator and Director of Nursing on 4/29/21 at 11:30 AM, the Director of Nursing confirmed the above findings.