Every finding on record at Audubon Home Health, Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS (Centers for Medicare and Medicaid Services) system within 30 days of completion. Review of the agency’s policy titled, “OASIS Data Transmission” with a revision date of April 2018 revealed the following, in part: Purpose: To outline the OASIS data transmission requirements. Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information. Procedure: 1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty days of the M0090 date, date assessment completed. Review of the agency’s OASIS Final Validation Report with a submission date of 05/18/2024 revealed 169 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 05/24/2024 revealed 140 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 06/04/2024 revealed 142 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 07/12/2024 revealed 146 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 07/26/2024 revealed 194 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2ADON on 08/08/2024 at 10:00 a.m. He confirmed the above records were submitted late. He stated OASIS Assessments should have been submitted within 30 days of completion.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to ensure Home Health Aide Supervisory visits were conducted every fourteen days for 1 (#5) of 3 (#4, #5, and #12) patients reviewed with Home Health Aide Services. Review of the agency’s policy Titled, “Home Health Aide Supervisory Visits” with a revision date of April 2018 revealed the following, in part: Purpose: To establish guidelines for the responsibilities and the frequency of supervisory visits for home health aide personnel. Policy: The registered nurse or other appropriate skilled professional that is familiar with the patient, the patient’s plan of care, and the written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals. Procedure: 1. The frequency of supervisory visits will be based upon the needs of the patients after the plan of care is established. They must be conducted no less frequently than every 14 days if the patient is receiving skilled services. Review of Patient #5’s Clinical Record revealed she began receiving services from the agency on 05/08/2024, had a current certification period of 07/07/2024 through 09/04/2024, and diagnoses, which included Hypertensive Heart Disease with Heart Failure, Encephalopathy, Spondylosis Without Myopathy or Radiculopathy – Lumbar Region, Other Cervical Disc Degeneration, and History of Falling. Review of Patient #5’s Physician Ordered discipline frequency revealed she received Home Health Aide visits twice weekly for three weeks and Occupational Therapy (OT) visits once weekly for three weeks. Review of Patient #5’s Home Health Aide visits revealed she had visits on 07/09/2024, 07/12/2024, 07/16/2024, 07/19/2024, 07/23/2024, and 07/26/2024. Review of Patient #5’s OT Visit Notes dated 07/23/2024 completed by S3OT revealed the following, in part: Were supervisory functions performed? – No Review of Patient #5’s Supervisory Visit Note signed by S3OT dated 07/23/2024 revealed it was blank. An interview was conducted with S3OT on 07/31/2024 at 1:13 p.m. S3OT confirmed she conducted Patient #5’s OT discharge assessment. S3OT stated she had never performed an aide supervisory visit for Patient #5. An interview was conducted with S1DON on 07/31/2024 at 1:18 p.m. S1DON reviewed Patient #5’s clinical record and confirmed an aide supervisory visit should have been conducted by S3OT on 07/23/2024. S1DON confirmed there was no documentation in Patient #5’s Clinical Record an aide supervisory visit was completed. S1DON confirmed Aide Supervisory Visits should have been conducted at least every fourteen days and were not.

Recertification and Relicensing COVID-19 Focused Infection Control Survey with no related deficiencies cited. Abbreviations: mg milligram PT Physical Therapy PTA Physical Therapy Assistant WK week

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 observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using and/or did not reflect medications the patients were no longer using, for 3 (#1, #2, and #5) of 7 (#1-#7) patients reviewed who received home visits. Findings: Review of the agency policy titled, "Medication Profile" revealed, in part, the following: Policy: Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. Patient #1 Review of the clinical record revealed a start of care date of 08/17/2021 with diagnoses that included Acute Cystitis without Hematuria, Acute Kidney Failure, Long Term use of Anticoagulants and Polyneuropathy. Review of the current medication profile as of 08/23/2021 for Patient #1 revealed the following, in part: Benzonate 100 mg capsule 3 times daily Doxazosin 1 mg tablet daily Gabapentin 100 mg capsule daily Warfarin 2.5 mg 1 tablet Mondays, Tuesdays, Wednesdays, Thursdays, Fridays and Sundays Warfarin 2.5 mg 1 tablet Saturdays A home visit was conducted with Patient #1 on 08/24/2021 at 9:00 a.m. An interview was conducted with Patient #1's daughter at that time. She provided Patient #1's medications for review. She stated her sister would oversee what medications the patient needed to take. A review of the patient's medication bottles was conducted and the following was observed: Benzonate 100 mg capsule 3 times a day as needed Gabapentin 100 mg capsule daily as needed Warfarin 2.5 mg Tuesday, Thursday, Saturday Warfarin 1.5 mg other days (Monday, Wednesday, Friday, Sunday) Further review of the medication bottles in the patient's home revealed the patient was not current taking Doxazosin 1 mg tablet daily. An interview was held with Patient #1's daughter on 08/24/2021 at 9:30 a.m. She said she was unaware of her mother taking Doxazosin 1mg tablet daily. She stated her mom knew what medications she was supposed to take. An interview was held with Patient #1 on 08/24/2021 at 9:35 a.m. She was unable to state that she was taking the medication Doxazosin currently. Patient #2 Review of the clinical record for Patient #2 revealed she began receiving services with the agency on 08/10/2021 and had diagnoses that included Parkinson's syndrome, and Chronic Pain Syndrome. Review of the current medication profile as of 08/23/2021 revealed the following, in part: Ondansteron 8 mg disintegrating 1 tablet daily. A home visit was conducted in the home of Patient #2 on 08/24/2021 at 10:30 a.m. An interview was held with the patient at that time. Patient #2 was able to verbalize all of the medications she was taking daily. She verbalized knowledge of the names of the medications she was taking and the reason. Patient #2 was asked if she took Ondansteron daily as it was listed on her medication profile. She denied taking the medication daily and stated she only took it as needed. Patient #5 Review of the clinical record for Patient #5 revealed she began receiving services with the agency on 11/21/2020 and had diagnoses that included Chronic Kidney Disease, Type II Diabetes Mellitus, and Venous Insufficiency. Review of the current medication profile as of 08/23/2021 revealed the following, in part: Doxazosin 4mg tablet daily Lasix 80mg tablet 1 tablet daily Lidocaine HCL 2% topical cream Triamterene 37.5 mg Hydrochlorothiazide 25mg 1 tablet daily Zetia 10mg tablet daily A home visit was conducted in the home of Patient #5 on 08/24/2021 at 1:30 p.m. An interview was held with the patient at that time. Patient #5 was able to verbalize all of the medications she had been taking daily. She verbalized knowledge of the names of the medications she was taking and the reason. She said her doctor increased Doxazosin to 8mg daily on 08/17/2021. She said she takes Lasix 80 BID and Triamterene 37.5 mg Hydrochlorothiazide 25mg 2 tablets daily since January 2021. She said she had never taken Zetia 10mg and was unsure why it was listed on her medication profile. She said she was out of Lidocaine HCL 2% topical cream for approximately 6 months and needed to get the prescription refilled soon. On 08/27/2021 at 10:15 a.m., an interview was conducted with S1DON. She was notified of the medication discrepancies found during the home visits for Patients #1, #2, and #5. She verified the medication profiles were not up to date. S1DON verified nurses should reconcile medications during each visit and update the medication profile accordingly.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the plan of care was signed and dated by the patient's physician in a timely manner for 5 ( #9, #10, #11, #16, and #17) of 17 (#1-#17) sampled patients. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #9 Review of the clinical record for Patient #9 revealed a start of care date of 07/08/2021. Review of the plan of care for the certification period 07/08/2021 to 09/05/2021 for the patient revealed a principal diagnosis of Spondylosis without Myelopathy. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #10 Review of the clinical record for Patient # 10 revealed a start of care date of 07/09/2021. Review of the plan of care for the certification period 07/09/2021 to 09/06/2021 for the patient revealed a principal diagnosis of Chronic Kidney Disease with Heart Failure. Further review of the Plan of Care revealed a physician signature dated 08/13/2021 which was greater than 30 days from the start of the certification period. Patient #11 Review of the clinical record for Patient #11 revealed a start of care date of 07/02/2021. Review of the plan of care for the certification period 07/02/2021 to 08/30/2021 for the patient revealed a principal diagnosis of Pneumonia. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #16 Review of the clinical record for Patient # 16 revealed a start of care date of 03/30/2021. Review of the plan of care for the certification period 03/30/2021 to 05/28/2021 for the patient revealed a principal diagnosis of Pneumonia. Further review of the Plan of Care revealed a physician signature dated 05/05/2021 which was greater than 30 days from the start of the certification period. Patient #17 Review of the clinical record for Patient # 17 revealed a start of care date of 01/15/2021. Review of the plan of care for the certification period 01/15/2021 to 03/15/2021 for the patient revealed a principal diagnosis of COVID-19. Further review of the Plan of Care revealed a physician signature dated 02/19/2021 which was greater than 30 days from the start of the certification period. On 08/27/2021 at 11:00 a.m., an interview was conducted with S1DON. After reviewing the plans of care for Residents #10, #16, and #17, she verified the physicians' orders were not signed for the patients within the required time frame of 30 days. She confirmed the physician had not signed the plan of care for Patient #9 and #11. She said she was responsible for ensuring the patient's plan of care was signed by the physician.