Every finding on record at Aviense Home Healthcare Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 7/3/24. Standard level deficiencies cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on the review of the Emergency Preparedness plan and staff interview, it was determined that the Agency failed to conduct required testing of the Emergency Preparedness plan. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan was reviewed on 7/2/24. The Emergency Preparedness plan lacked documentation that the Agency conducted / participated in any community-based testing exercises, since 2021. 2. The findings were confirmed during the interview, with the Administrator on 7/3/24 at 10:00 AM.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: W = week # = number % = percent ( AM = morning x = times or by (>) = greater than ABD = Abdominal SN = Skilled Nurse POC = Plan of care SOC = Start of care BP = Blood Pressure PsOC = Plans of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist

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 review of the Error Summary report and staff interview, it was determined that in 146 of 229 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 4/2023 to 3/2024 (12 months) was reviewed on 7/1/24. The report included a warning for 146 (63.76 %) of 229 assessments with Error # -3330 Record submitted late, more than 30 days after completing the assessment. 2. During an interview with the Alternate Director of Nursing/Clinical Manager on 7/1/24 at 1:30 PM, the Alternate Director of Nursing/Clinical Manager confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 2 of 7 (Pts. #3 and 4) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or the initial assessment visit was done within 48 hours of the referral. Findings include: 1. Pt. #3 was admitted for home health services on 6/16/24 with the primary diagnosis of Essential Hypertension. The clinical record was reviewed on 7/1/24. The record contained the SOC comprehensive assessment completed by the SN and dated 6/16/24. As of 7/1/24, the record lacked a referral for the SOC visit conducted on 6/16/24. 2. Pt. #4 was admitted for home health services on 2/19/24 with the primary diagnosis of Stage 4 Pressure Ulcer of Sacral Region. The clinical record was reviewed on 7/1/24. The record contained the SOC comprehensive assessment completed by the SN and dated 2/19/24. The referral was completed by an Advanced Practice Nurse and faxed to the Agency on 2/12/24. As of 7/1/24, the record lacked a reason for the late SOC. 3. The Agency's policy titled, "Clinical Records/Medical Record Retention" was reviewed on 7/3/24. The policy included: "...2... the clinical record shall contain appropriate identifying information, including, but not limited to: a. Intake Referral form..." 4. During an interview with the Alternate Director of Nursing/Clinical Manager on 7/2/24 at 1:30 PM, the Alternate Director of Nursing/Clinical Manager confirmed the Agency failed to ensure a referral was obtained to initiate service or the initial assessment visit was not done within 48 hours of the referral.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on observation and interviews during a home visit, clinical record review and staff interview, it was determined that for 1 of 2 (Pt. #1) Pts. receiving wound care, the Agency staff failed to conduct, and document an assessment that reflects the patient’s current health status. Findings include: 1. Pt. #1 was admitted for home health services on 6/16/24 with the primary Diagnosis of Cellulitis of the Groin. A home visit was conducted on 7/2/24 with the Administrator/Licensed Practical Nurse, who provided treatment for the wound on the right lower leg area, as follows: cleansed the wound with normal saline solution, applied a dressing of 3% bismuth tribomophenate and petrolatum and covered it with a border dressing. During an interview conducted with Pt. #1 at the home visit, it was stated that the wound on the right lower leg area is better than it had been. The clinical record was reviewed on 7/3/24. The document titled “Medication Review Report” from the Skilled Nursing Facility dated 6/13/24 included documentation that Pt. #1 had a surgical wound on right lower medial leg. The comprehensive assessment which was completed by the RN on 6/16/24 lacked documentation of the assessment/description of the right lower medial leg surgical wound. 2. During an interview conducted with the Administrator on 7/3/24 at 11:00 AM, the above finding was confirmed.

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 during a home visit, clinical record review, policy review and staff interviews, it was determined for 1 of 2 (Pt. #1) Pts. who were receiving wound care, the Agency failed to ensure PsOC included all the requirements. Findings include: 1. Pt. #1 was admitted for home health services on 6/16/24 with a primary Diagnosis of Cellulitis of the Groin. A home visit was conducted on 7/2/24 with the Administrator/Licensed Practical Nurse, who provided treatment for surgical wounds on the right lower leg area and the right groin area. The clinical record which was reviewed on 7/3/24 included a POC effective 6/16/24. The POC lacked documentation of the description of the wounds and measurable goals for wound healing, the procedure, the equipment and supplies used for its treatment. 2. The policy “Plan of Care – CMS #485 and Physician Orders” was reviewed on 7/3/24 and required, “2. …Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals… 4. The individualized plan of care must include the following: the types of services and equipment required… all medications and treatments… 3. During an interview conducted with the Administrator on 7/3/24 at 11:00 AM, the Administrator confirmed that the POC should include documentation of required entries. During the same interview, the above finding was confirmed.

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 a review of clinical record, and staff interviews, it was determined for 3 of 7 (Pts. #4, 5 and 1) clinical records reviewed, the Agency failed to ensure staff provided services in accordance with the POC, and as indicated by the Physician. 3. Pt. #1 was admitted for home health services on 6/16/24 with the primary diagnosis of Cellulitis of the Groin. The clinical record was reviewed on 7/3/24. The POC effective 6/16/24 required, “SN Frequency: 2W2, 1W7…” The record lacked documentation of a second SN visit during the week of 6/16/24 to 6/22/24. The record lacked also documentation of the reason of the missed visit and that the physician was notified of the missed visit. 4. The policy “Plan of Care – CMS #485 and Physician Orders” was reviewed on 7/3/24 and required, “The Agency must maintain documentation in the clinical record indicating the physician was notified and is aware of the missed visit.” 5. The policy "Clinical Documentation" was reviewed on 7/3/24 and required, "Services not provided and the reason for the missed visits will be documented on a missed visit report form and reported to the physician." 6. During an interview was conducted with the Administrator and the Alternate Director of Nursing/Clinical Manger on 7/2/24 at 1:30 PM, and on 7/3/24 at 11:00 AM, the above findings were confirmed. Findings include: 1. Pt. #4 was admitted for home health services on 2/19/24 with the primary diagnosis of Stage 4 Pressure Ulcer of Sacral Region. The clinical record was reviewed on 7/1/24. The record contained the POC for the certification period of 4/19/24 to 6/17/24 that required: “SN to perform pressure ulcer care to sacrum with each visit. Cleanse/irrigate wound with saline solution, apply Medi-Honey gel, then cover with 4x4 folded gauze in several layers, cover with ABD pad, then secure with Rite-Fix tape, using aseptic technique.” The SN visit note dated 5/16/24 lacked documentation the SN provided pressure ulcer care to the sacrum. The POC effective 4/19/24 required, “SN Frequency: 1W9”. The record lacked documentation the SN provided service during the weeks of 5/5/24 to 5/11/24 and 5/26/24 to 6/1/24. The record lacked the reason of the missed visit, and that the physician was notified of the missed visit. The POC effective 4/19/24 required the SN: “Notify Physician of vital sign parameters out of range… Diastolic BP: Greater Than (>) 90 Less Than ( The recertification comprehensive assessment completed by the SN and dated 6/15/24 included BP 140/46. The record lacked documentation the Physician was notified of the Diastolic BP of 46. 2. Pt. #5 was admitted for home health services on 4/5/24 with the primary diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 7/2/24. The record contained the POC effective 6/4/24 that required: “Physical Therapy to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence…” As of 7/2/24, the record lacked documentation the PT assessed the Pt. on or after 6/4/24.

An investigation was conducted on 4/4/23 for complaint #971118/2320428. Standard level deficiencies cited. Abbreviations: AM =morning PM = afternoon DON = Director of Nursing # = number

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on Agency documents, personnel files and interview it was determined the Agency failed to ensure that the Agency has a qualified Nursing Supervisor. This has the potential to affect all services provided by the Agency. Findings include: 1. On 4/4/23 at 10:30 AM E#3 arrived at the Agency and introduced herself as the Alternate Agency Supervisor/Director of Nursing since 12/1/22. E#3 stated during an interview at 10:45 AM that E#5 (Former Nursing Supervisor/Director of Nursing) resigned on 11/23/22, E#6 was the Director of Nursing from 12/6/22 to 12/13/22. The position has been vacant since 12/13/22. 2. The Agency license application dated 8/5/22 documented E#5 (former Employee) as Agency Supervisor. 3. E#3's personnel file contained a signed job description for Alternate Director of Nursing. E#3 assumed the role of Alternate Director of Nursing effective 12/1/2022. 4. During an interview with E#2 and E#3 on 4/4/2023 at 2:00PM they confirmed that the Director of Nursing position has been vacant since 12/13/22.