Every finding on record at Carewell Health Services, Inc

A recertification inspection survey was conducted on 01/11/2023. L & CHHS census was 29. No deficiencies were cited. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification inspection survey was conducted on 01/11/2023 with follow-up for survey dated 01/23/2020. L & CHHS census was 29. Deficiencies were cited. Abbreviations and Acronyms: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nurses (Supervising Nurse) ADON-Assistant Director of Nurses (Alternate Supervising Nurse) L & CHHS- Licensed and Certified Home Health Services Licensed Vocational Nurse (LVN) hha-Home Health Aide POC- Plan of Care SOC- Start of Care HHA- Home Health Agency PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement QA- Quality Assurance SN- Skilled Nursing

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, in two (Patients # 1and # 2) of three records reviewed with home visits, the agency failed to ensure that the patient and caregiver received ongoing education and training regarding care and services identified in the plan of care. The failure could place the patients at risk of injury and poor patient outcomes due to education and training not being provided to the patient/caregiver. FINDINGS INCLUDED: Patient # 1: Review of Patient # 1’s clinical record revealed a POC for the certification period 11/02/2022 to 12/31/2022, signed by the ADON and dated 11/02/2022. The POC had a SOC date of 11/02/2022. The POC included a primary diagnosis of Pressure ulcer of sacral region, stage 3. The POC included orders for SN visits two times per week for one week and three times per week for eight weeks. Further review of the POC revealed that it included orders for SN to instruct patient/caregiver regarding management of Depression. During a home visit with Patient # 1 on 01/09/2023 at approximately 4:45 p.m., Patient # 1 stated, “I’m getting too old for this. I called my son and told him he can take me off anytime he wants to.” Patient #1 also stated “[my family member] has passed away and it’s just me.” Review of SN visit notes dated 11/04/2022 through 12/28/2022 revealed that LVN A conducted the visits. Continued review of the SN visit notes did not reveal that LVN A had provided instruction to Patient # 1 and caregiver regarding management of depression. There was no documentation in Patient # 1’s clinical record for the certification period of 11/02/2022 to 12/31/2022 that revealed LVN A had provided instruction/teaching on managing depression. During an interview with the Adm and LVN A, on 01/11/2023 at approximately 11:00 a.m., the surveyor discussed the above findings and asked LVN A why Patient # 1 and caregiver had not been provided instruction regarding management of depression. LVN A replied, “When I talk to him it [depression] did not look immediate.” Patient # 2: Review of Patient # 2’s clinical record revealed a POC for the certification period 12/09/2022 to 02/06/2023, signed by the ADON and dated 12/08/2022. The POC had a SOC date of 10/15/2021. The POC included a primary diagnosis of chronic kidney disease, stage 2. The POC included orders for SN visits zero times per week for one week, two times per week for eight weeks and zero times per week for one week. Further review of the POC revealed that it included orders for SN to instruct patient/caregiver on pressure ulcer prevention as well as treatment methods… to prevent pressure ulcer development. During a home visit with Patient # 2 on 01/10/2023 at approximately 8:00 a.m., the surveyor observed that Patient # 2 was unable to reposition herself in bed or get out of bed without assistance. The surveyor asked Patient # 2 what services hha A provided. Patient # 2 replied, “[hha A] helps me with everything. I can’t do anything for myself.” Review of SN visit notes dated 12/15/2022; 12/22/2022and 12/29/2022 revealed that LVN A conducted the visits. Continued review of the SN visit notes did not reveal that LVN A had provided instruction to Patient # 2 and caregiver regarding pressure ulcer prevention as well as treatment methods… to prevent pressure ulcer development. There was no documentation in Patient # 2’s clinical record for the certification period of 12/09/2022 to 01/05/2023 that revealed LVN A had provided instruction/teaching on pressure ulcer prevention as well as treatment method… to prevent pressure ulcer development. During an interview with the Adm and LVN A, on 01/11/2023 at approximately 11:00 a.m., the surveyor discussed the above findings and asked LVN A why Patient # 2 and caregiver had not been provided instruction regarding pressure ulcer prevention as well as treatment method… to prevent pressure ulcer development. LVN A replied, “I was documenting it when [Patient # 2] had an open wound.” During an interview with the Adm and ADON at approximately 10:50 a.m., the surveyor asked how the agency monitored to ensure the POC(s) for Patient # 1 and # 2 had been implemented as ordered. The Adm stated that monitoring is, “A part of Q.A., so that should be brought to my attention and nurses’ attention if it is not happening.” Review of agency policy titled “Monitoring Patient Care/Coordination of Care PC.10” revised 080120 read in part: “Procedure…E. Ensure that each patient/client, and his or her caregiver…receive ongoing education and training provided by the Agency…regarding the care and services identified in the plan of care…to ensure timely discharge…” Review of agency policy “Agency Philosophy on Patient/Client Education PF.1” revised 011318 read in part: “…Procedure…I. Education to improve health outcomes as appropriate to the care provided by the agency will be accomplished by…G. Coordinating patient/client and caregiver educational needs with all disciplines involved in the Plan of Care and care provided…” Review of agency policy titled “Continuous Interdisciplinary Patient/Client Education PF.3” revised 011318 read in part: “…Procedure…IV. Continuous patient/client education will be facilitated by all disciplines involved in the patient’s/client’s Plan of Care through…D. Appropriate disciplines teaching necessary skills and behaviors needed to improve the patient’s/client’s health outcomes…”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to document PIP(s) for the calendar years 2020, 2021 and 2022 that reflected the scope, complexity and past performance of the agency's services and operations. The failure placed the agency's patients at risk of negative patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDED: During the entrance conference on 01/05/2023 at 1:20 p.m. the surveyor requested the agency’s QAPI reports/records and documents. At 3:00 p.m., the Adm provided a QAPI binder and stated that the agency was still working on the 3rd and 4th quarter for 2022. The surveyor requested the 3rd and 4th quarter QAPI records at approximately 3:30 p.m. The Adm stated that the agency’s Consultant was working on the documents. The surveyor requested that the consultant faxed the records to the agency. At 4:30 p.m. the Adm stated that the Consultant was not responding to text message requests for the documents. At 5:05 p.m. the Adm stated that the Consultant did not answer a phone call from the Adm. The Adm also stated that all requested records from “Home Care Request list” dated 01/05/2023 had been provided to the surveyor, except 3rd and 4th quarter QAPI reports. The 3rd and 4th quarter QAPI documents had not been provided to the surveyor prior to leaving the agency at 6:00 p.m. Review of the agencies QAPI binders, documents, and reports did not reveal any reports, reviews or documentation that indicated the agency had documented PIP(s) per federal regulatory requirements, for the years 2020, 2021 and 2022. The QAPI binder contained “Quality Assessment Performance Improvement” quarterly reports. The binder also contained a form titled “QAPI Performance Improvement Project (PIP)”. The PIP form was blank. The QAPI records did not reveal any completed PIP forms that: reflected the scope, complexity, and past performance of the HHA's services and operations; and that documented the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. During an interview with the Adm on 01/11/2023 at 10:54 a.m., the surveyor discussed the above findings and asked where the documentation for the agency’s PIP(s) for the years 2020, 2021 and 2022 was located. The Alt Adm replied, “If it is not in the QAPI book, then I don’t have it.” Review of agency policy titled “Quality Assessment Performance Improvement Program QAPI.1” Revised 011318 read in part: “ Purpose To develop, implement, evaluate, and maintain an effective, ongoing Agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) Program…Policy…The Governing Body will ensure that the QAPI program…involves all agency services…The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS…Procedure…D. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…X. QAPI documents will…be made available to the State Home Health licensing Agency…”