Every finding on record at Authoracare Collective

A recertification survey was conducted on February 28, 2022. No deficiencies to the Emergency Preparedness Plan identified.

A recertification survey was conducted February 28, 2022. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 and staff interview, the agency failed to have patient specific oxygen saturation parameters for 1 of 1 patients (#2) with pulse oximetry reading outside of normal range. Findings include: Patient #2 was admitted on 9/6/18 with hypoplastic left heart syndrome (congenital heart defect in which the left side of the heart is underdeveloped), double outlet right ventricle (congenital heart defect), and pulmonary hypertension (pressure from blood vessels leading from the heart to the lungs is too high). The Plan of Care for 4/23/21-6/21/21 included orders for skilled nursing weekly for nine weeks; perform pulse oximetry as needed for cardiopulmonary status. Between 4/23/21-6/14/21, the pulse oximetry readings ranged from 85%-88%. There were no patient specific ranges for physician notification. An interview with the program director on 2/28/22 at 3:30 p.m. confirmed the POC did not include patient specific parameters. The interview revealed the parameters had been on a previous POC within a different electronic medical record but had not been entered into the new electronic medical record system.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency record failed to include orders for treatments for 1 of 8 patients (#2). Findings include: A policy, “Plan of Care” revised 9/24/21, was provided by Director of Compliance on 2/28/22 at approximately 4:00 p.m. The policy stated, “Any changes to the care plan will be noted in the clinical record as well as be evidenced by new physician orders.” Patient #2 was admitted on 9/6/18 with hypoplastic left heart syndrome (congenital heart defect in which the left side of the heart is underdeveloped), double outlet right ventricle (congenital heart defect), and pulmonary hypertension (pressure from blood vessels leading from the heart to the lungs is too high). The Plan of Care for 4/23/21-6/21/21 included orders for skilled nursing weekly for nine weeks. A Clinical Note on 4/23/21 stated, “PRN (as needed) visit made to attempt to remove sutures from abdomen after receiving verbal order from Dr. ____. [Patient] had an appointment with Dr. ___, cardiology, this morning and Dr. ___ was unable to remove sutures. This nurse was willing to look at the sutures and attempt to remove it [sic] possible…SN attempted to remove sutures but the sutures were imbedded too far into the skin and in a few places the skin had grown over the sutures. [Patient’s mother] contacted Dr. ____ office to make him aware that the surgical team would have to remove the sutures on Monday after all…” An interview with the program director on 2/28/22 at 3:30 p.m. confirmed the clinical record did contain an order to remove sutures.

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 policy review, clinical record review and staff interview, the agency failed to follow the Plan of Care for providing phone calls to 2 of 8 patients (#2 and 1); and obtaining vital signs as ordered for 3 of 8 patients (#2, 4, 8, and 5). Findings include: 4. Patient # 1 had a Start of Care [SOC] date of 11/27/17 and admitting diagnoses of Other Hereditary Ataxias [a group of genetic disorders characterized by slowly progressive incoordination of gait] and Epilepsy [disorder causing seizures]. A review of the Plan of Care [POC] for the certification period 1/10/21 to 3/10/21 revealed orders for SN [skilled nursing] 1-3 times per week and weekly virtual/telephonic visits once every 2 weeks. A review of the clinical record revealed no virtual/telephonic visits were made during that certification period. An interview was conducted with RN # 3 on 2/28/22 at approximately 4:20 pm. During the interview the RN confirmed virtual/telephonic visits were not conducted in accordance with the POC. 5. Patient #3 was admitted on 09/09/2020 with a diagnosis of Atrioventricular septal defect (a heart defect affecting the valves between the heart’s upper and lower chambers and the walls between the chambers.) The Plan of Care (POC) for 11/08/2020 through 01/06/2021 included orders for skilled nursing visits 1 time per week for 9 weeks. In a clinical record review of the POC, it specifies orders for skilled nursing to “Assess vital signs every visit.” On 03/03/2021, 03/12/2021 and 03/17/2021 no vitals signs were documented. A staff interview with manager #3 on 02/28/2021 at 4:45 p.m. confirmed the nurse did not obtain vital signs. A policy, “Plan of Care” revised 9/24/21, was provided by Director of Compliance on 2/28/22 at approximately 4:00 p.m.. The policy stated, “The plan of care shall include but is not limited to…Types of services, supplies, and equipment needed…Orders for disciplines, frequency, and duration of visits…” 1A. Patient #2 was admitted on 9/6/18 with hypoplastic left heart syndrome (congenital heart defect in which the left side of the heart is underdeveloped), double outlet right ventricle (congenital heart defect), and pulmonary hypertension (pressure from blood vessels leading from the heart to the lungs is too high). The Plan of Care for 4/23/21-6/21/21 included orders for skilled nursing (SN) weekly for nine weeks, “Weekly Virtual/Telephonic visit frequency: 1x/week.” Between 4/23/21-6/14/21, there was no evidence of virtual of telephonic visits. An interview with the program director on 2/28/22 at 3:30 p.m. revealed the order should have been for in-person or virtual/telephonic visits as requested by the caregiver. 1B. The Plan of Care for patient #2 for 4/23/21-6/21/21 included orders for skilled nursing weekly for nine weeks; assess vital signs every visit. Respirations ranged from 22-36. Between 4/23/21-6/14/21, there were no respirations for 3 of 9 visits. An interview with the program director on 2/28/22 at 3:30 p.m. confirmed the respirations were missing for 3 visits. 2. Patient #4 was admitted on 8/15/16 with cerebral palsy and obstructive sleep apnea. The Plan of Care (POC) for 1/27/20-3/26/20 included orders for skilled nursing weekly for eight weeks; assess vital signs every visit. Between 1/27/20-3/25/20, 1 of 7 visits did not include a blood pressure. An interview with the program director on 2/28/22 at 3:45 p.m. confirmed vital signs were not completed as ordered. 3. Patient #8 was admitted on 10/10/19 with unspecified intestinal obstruction. The Plan of Care (POC) for 2/7/20-4/6/20 included orders for skilled nursing (SN) weekly for nine weeks; and to assess vital signs every visit. Between 2/6/20-2/20/20, there were 2 nursing visits conducted. The visit on 2/6/20 was missing the blood pressure, and the visit on 2/13/20 was missing the temperature. An interview with the program director on 2/28/22 at 3:50 p.m. confirmed vital signs were not completed as ordered.

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 and staff interviews the agency failed to obtain an order to hold tube feedings for 1 of 1 record with a diagnosis of Encephalopathy [#5]; failed to obtain an order for medication/tube feeding changes for 2 of 2 records with a diagnosis with documented changes [#5 and 6]. The findings included 2. Patient #6 was admitted on 04/07/2017 with a diagnosis of Mucopolysaccharidosis, type II (a rare and progressive inherited disease.) The POC 03/17/2021 through 05/15/2021 included orders for skilled nursing visits 1 time per week for 8 weeks with 4 PRN (as needed) visits for education, support and symptom management. Medications listed on the POC for 03/17/2021 to 05/15/2021 included Diazepam by mouth tablet 5 mg 5 milligrams as needed as prescribed PRN- every six hours for Gelastic Seizures ( focal or partial seizures with bouts of uncontrolled laughing or giggling.) or Agitation via G-tube…Oxycodone HCL by mouth solution 5mg/5ml 3-5milliliter as needed as prescribed PRN- every four hours via G-tube for moderate- severe pain.” Nutritional orders listed on POC include “Miralax by mouth powder 17 GM/scoop 17 gram 1 time a day as prescribed via G-tube…Elecare Jr by mouth powder 1 powder with meals as prescribed add 6 scoops to 225 ml of water and infuse three times a day via G-tube; rate as tolerated…Amino acids by mouth powder 0.5 teaspoon 3 times a day as prescribed add ½ teaspoon to each feeding…add ½ tsp of amino acid powder to each feeding (three times a day).” In a clinical record review of nursing assessments the nurse documented on 03/23/2021 patients caregiver “was able to speak with Dr. _____ last Friday and was given recommendations on what to do for agitation (… give an extra 2.5mg valium if needed, give extra 2.5mg oxycodone if needed)…” And on 04/27/2021 documented the patients caregiver reported “that Gi/nutrition changed the feeding pattern last week. She is to make up a 24 hour feed every morning consisting of 19 ½ oz Pedialyte and 13 scoops of elecare jr. Breakfast feed: 300ml of the above mix plus 1 tsp amino acid and miralax. Lunch feed: 200ml of above mix plus 1tsp amino acid, Dinner feed: 160-170ml of above mix plus 1tsp amino acid.” In a clinical record review, it was noted there was no evidence of the nurse communicating with physician to clarify the medication and nutritional changes. A staff interview with manager #3 0n 02/28/2022 at 5:10 p.m. stated the expectation of the nursing staff would be to contact the physician to clarify the changes in POC. Manager #3 confirmed the nurse did not communicate with the physician. 1A. Patient # 5 had a Start of Care [SOC] date of 6/8/18 and an admitting diagnosis of Encephalopathy [disease of the brain]. A review of the Plan of Care [POC} for the certification period 1/29/20 to 3/28/20 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks and “Compleat Pediatric [tube feeding] 120 ml to infuse over one hour three times a day and 125 ml to infuse from 9 pm – 11 pm…” A review of the clinical record revealed a routine visit was made by RN # 5 on 2/7/20. A review of the documentation revealed the following information, “…Skilled nurse suggested that she [mother] hold his feedings for the next twelve hours and slowly start Pedialyte; titrating upward and adding in the formula…” Further review of the clinical record revealed no physician’s order related to holding the feeding. An interview was conducted with RN # 3 on 2/28/22 at approximately 4:20 pm. During the interview the RN confirmed there was no order related to holding the feeding. 1B. Patient # 5 had a Start of Care [SOC] date of 6/8/18 and an admitting diagnosis of Encephalopathy [disease of the brain]. A review of the Plan of Care [POC} for the certification period 1/29/20 to 3/28/20 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks. A review of the clinical record revealed a routine visit was made by RN # 5 on 2/7/20. A review of the documentation revealed the following information, “…She [mother] said that she had spoke [sic] with Dr. ______ [name] earlier today and she instructed her to go up to 8 teaspoons on the Miralax [sic] [laxative] daily…” A review of the POC revealed the order for the MiraLax was 4 tablespoons [12 teaspoons] 1 time per day as needed for constipation. An interview was conducted with RN # 3 on 2/28/22 at approximately 4:20 pm. During the interview the RN confirmed there was no order for the MiraLax to be changed to 8 teaspoons per day.

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 policy review, personnel record review, and staff interview, the agency COVID-19 Vaccination policy did not contain all required elements. The findings include: The “Mandatory COVID-19 Vaccine Policy” was provided by the Vice President of Quality on 2/28/22 at 4:20 p.m. The policy failed to include: A. 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: all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized reasons for the contraindications; AND a statement by the authenticating practitioner recommending that the staff member be exempted from the home health agency’s COVID-19 vaccination requirements for staff based on the recognized clinical contraindications. Employee #1 requested a medical exemption on 11/24/21. The exemption was approved on 12/1/21. The exemption did not include which authorized COVID-19 vaccines were clinically contraindicated. B. 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 illnesses secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment. Employee #2 requested a medical exemption for “deferment of the vaccine to a later date” on 1/4/22 due to “Prior positive COVID-19 test.” The exemption was approved on 1/10/22. The agency did not have a process in place to track employees with deferments. An interview with the Vice President of Quality on 2/28/22 at approximately 5:00 p.m. confirmed the policy was missing some elements and the medical exemption did not include all required information.