Every finding on record at Chadds Ford Alternacare Inc.

Based on the findings of an unannounced on-site Medicare recertification survey conducted February 14, 2024, through February 16, 2024, and February 20, 2024, Criticare Home and Nursing Serices was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced on-site Medicare recertification survey conducted February 14, 2024, through February 16, 2024, and February 20, 2024, Criticare Home and Nursing Services was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on the review of agency policies, clinical records (CR), and interviews with agency staff, the agency failed to ensure that staff documented that services were provided in accordance with the plan of care for four (4) of seven (7) CR reviewed. (CR # 2, 3, 4, and 7) Findings include: Review of agency Policy #C-2.0 “Acceptance of Patients, Plan of Care, and Medical Supervision” on February 20, 2024, at approximately 3:10 P.M. stated, “Procedure: 2. Plan of Care: Care follows a written plan of care established and periodically reviewed by a doctor of medicine or osteopathy (the physician)… B. The plan includes: … iv. The types of services, supplies, and equipment required…xvii. Patient-specific interventions and education… 3. Conformance with Physician Orders: B. Plan of Care: must be sent to the physician for signature. i. It is the physician’s responsibility to review, sign and return the plan of care to Criticare Home Health and Nursing Services within fourteen (14) days… Review of agency Policy #C-6.0 “Administration of Medications and Therapies” on February 20, 2024, at approximately 3:20 P.M. stated, “Procedure: 2. Medication Review/Patient Education and Documentation: C. The Medication Profile is utilized to fully document all components of medication oversight and care management including: … iii. Patient’s drug regimen… iv. Who will administer the medication…” Review of CR on February 14, 2024, from approximately 10:00 A.M. to 2:00 P.M. and February 16, 2024, from approximately 9:30 A.M. to 2:00 P.M. revealed the following: CR #2, start of care November 27, 2019. Certification period reviewed: January 8, 2024, through March 5, 2024. The POC contained orders as follows: SN (skilled nurse): 110 Hrs (hours)/wk (week) for 10 wks starting from 01/06/2024. Review of nursing flow sheets revealed that SN services were only provided on January 10, January 24, January 31, 2024, and February 7, 2024, from 11:00 P.M. to 7:00 A.M., January 17, 2024, from 11:00 P.M. to 1:00 A.M., and January 29, 2024, from 3:45 P.M. to 4:45 P.M. There was no documentation that the case was shared with another agency and no physician notifications that services were not provided in accordance with the POC. There were no verbal orders to amend the duration and/or frequency of services provided. Review of the medications ordered on the POC revealed four (4) medications to be given daily, three (3) medication to be given two (2) times per day, and eight (8) medications to be given PRN. There were no medications documented as given on any of the dates that services were provided. The electronic record contained no documentation of the times that the medications were scheduled to be given. CR #3, start of care July 26, 2023. Certification period reviewed: January 22, 2024, through March 21, 2024. The POC contained orders as follows: SN 91 Hrs (hours)/wk (week) for 10 wks starting from 1/22/2024 - Criticare nurse attends school with the patient and normally works a 10 AM to 5 PM workday Monday - Friday. Review of nursing flow sheets revealed that SN services were provided Monday through Friday from January 22, 2024, through February 12, 2024, from 10:00 A.M. to 11:00 A.M, and 2:15 P.M. to 5:00 P.M. on all days except January 30, 2024, and February 5, 2024, when services were provided 2:15 P.M. to 3:00 P.M., and February 7, 2024, when services were provided 2:15 P.M. to 3:15 P.M. There was no documentation that the physician was notified that services were not provided in accordance with the POC. There was no documentation of a verbal order to amend the times that services were provided. The patient has a G/J tube (tube inserted through the abdomen into the stomach and the small intestine for feedings and medications). There was no documentation of the date of the last tube change. The POC contained no documentation of the type or size of tube, the frequency of replacement of the tube, emergency procedures if the tube becomes dislodged or blocked. There were no orders for care of the G/J tube and/or any water flushes to be completed with medications and/or feedings. The patient has a central venous catheter (CVC) (a surgically placed intravenous line inserted into a large vein in the chest) for TPN (total parenteral nutrition, complete nutrition provided intravenously). The CVC is managed by an infusion company and the mother. The POC does not contain any orders for emergency procedures if there would be a problem with the CVC, frequency of dressing changes, frequency of changes of the CVC lines, or the solution to be used for KVO (keep vein open), which is ordered to run at 5 ml (milliliters) per hour. Review of the medications ordered on the POC revealed eight (8) medications to be given daily, five (5) medication to be given two (2) times per day, two (2) medications to be give three (3) times per day, and ten (10) medications to be given PRN. The electronic record contained no documentation of the times that the medications were scheduled to be given. CR #4, start of care October 23, 2023. Certification period reviewed: December 22, 2023, through February 19, 2024. The POC contained orders as follows: SN [Insurance company] has authorized 91 Hrs/wk for 10 wks starting 12/22/2023. Nurse accompanies [patient] to school but this service is covered by the [school district]. Nurse performs nursing care in the home after school, half days, sick days and days off from school - covered by insurance. The POC was not signed by the physician with the allotted timeframe. Review of nursing flow sheets revealed services were provided mainly after school from 3:45 P.M. to approximately 5:00 P.M. Monday through Friday. There were occasional days that services were provided for a full or half day, but never for 91 hours per week. There was no documentation that the physician was notified that services were not provided in accordance with the POC. The POC did not contain orders for G-tube care to be provided. Review of the medications ordered on the POC revealed two (2) medications to be given daily, three (3) medication to be given two (2) times per day, and six (6) medications to be given PRN. The electronic record contained no documentation of the times that the medications were to be given. No medications were documented as given on January 4, January 8, January 16, January 18, January 22, January 30, and February 9, 2024. CR #7, start of care September 19, 2023. Certification period reviewed: September 25 ,2023, through November 23, 2023. The POC contained orders as follows: SN: 1W10 starting from 09/25/2023. PRN Visits/Hours: 4 (chronic htn) (hypertension, high blood pressure). Review of nursing flow sheets revealed that services were not provided during the week of October 1, 2023, through October 7, 2023. There was no documentation that the physician was notified of the missed visit. There were no verbal orders to amend the duration and/or frequency of services provided. An interview with the Director of Nursing, HR Coordinator, VP of Operations, and the Chief Financial Officer on February 16, 2024, at approximately 3:00 P.M. confirmed the above findings.

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 the review of agency policies, clinical records (CR), and interviews with agency staff, the agency failed to ensure that the medication profiles contained times of medication administration for three (3) of seven (7) CR reviewed. (CR # 2, 3, and 4) Findings include: Review of agency Policy #C-6.0 “Administration of Medications and Therapies” on February 20, 2024, at approximately 3:20 P.M. stated, “Procedure: 2. Medication Review/Patient Education and Documentation: C. The Medication Profile is utilized to fully document all components of medication oversight and care management including: … iii. Patient’s drug regimen… iv. Who will administer the medication…” Review of CR on February 14, 2024, from approximately 10:00 A.M. to 2:00 P.M. and February 16, 2024, from approximately 9:30 A.M. to 2:00 P.M. revealed the following: CR #2, start of care November 27, 2019. Certification period reviewed: January 8, 2024, through March 5, 2024. Review of the medications ordered on the POC revealed four (4) medications to be given daily, three (3) medication to be given two (2) times per day, and eight (8) medications to be given PRN. There were no medications documented as given on any of the dates that services were provided. The electronic record contained no documentation of the times that the medications were scheduled to be given. CR #3, start of care July 26, 2023. Certification period reviewed: January 22, 2024, through March 21, 2024. Review of the medications ordered on the POC revealed eight (8) medications to be given daily, five (5) medication to be given two (2) times per day, two (2) medications to be give three (3) times per day, and ten (10) medications to be given PRN. The electronic record contained no documentation of the times that the medications were scheduled to be given. CR #4, start of care October 23, 2023. Certification period reviewed: December 22, 2023, through February 19, 2024. Review of the medications ordered on the POC revealed two (2) medications to be given daily, three (3) medication to be given two (2) times per day, and six (6) medications to be given PRN. The electronic record contained no documentation of the times that the medications were to be given. No medications were documented as given on January 4, January 8, January 16, January 18, January 22, January 30, and February 9, 2024. An interview with the Director of Nursing, HR Coordinator, VP of Operations, and the Chief Financial Officer on February 16, 2024, at approximately 3:00 P.M. confirmed the above findings.

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 the review of agency policies, clinical records (CR), and interviews with agency staff, the agency failed to ensure that the plan of care contained orders for all care to be provided for two (2) of seven (7) CR reviewed. (CR # 3 and 4) Findings include: Review of agency Policy #C-2.0 “Acceptance of Patients, Plan of Care, and Medical Supervision” on February 20, 2024, at approximately 3:10 P.M. stated, “Procedure: 2. Plan of Care: Care follows a written plan of care established and periodically reviewed by a doctor of medicine or osteopathy (the physician)… B. The plan includes: … iv. The types of services, supplies, and equipment required…xvii. Patient-specific interventions and education… 3. Conformance with Physician Orders: B. Plan of Care: must be sent to the physician for signature. i. It is the physician’s responsibility to review, sign and return the plan of care to Criticare Home Health and Nursing Services within fourteen (14) days… Review of CR on February 14, 2024, from approximately 10:00 A.M. to 2:00 P.M. and February 16, 2024, from approximately 9:30 A.M. to 2:00 P.M. revealed the following: CR #3, start of care July 26, 2023. Certification period reviewed: January 22, 2024, through March 21, 2024. The patient has a G/J tube (tube inserted through the abdomen into the stomach and the small intestine for feedings and medications). The POC contained no documentation of the type or size of tube, the frequency of replacement of the tube, emergency procedures if the tube becomes dislodged or blocked. There were no orders for care of the G/J tube and/or any water flushes to be completed with medications and/or feedings. The patient has a central venous catheter (CVC) (a surgically placed intravenous line inserted into a large vein in the chest) for TPN (total parenteral nutrition, complete nutrition provided intravenously). The CVC is managed by an infusion company and the mother. The POC does not contain any orders for emergency procedures if there would be a problem with the CVC, frequency of dressing changes, frequency of changes of the CVC lines, or the solution to be used for KVO (keep vein open), which is ordered to run at 5 ml (milliliters) per hour. CR #4, start of care October 23, 2023. Certification period reviewed: December 22, 2023, through February 19, 2024. The patient has a G-tube. The POC did not contain orders for G-tube care to be provided. An interview with the Director of Nursing, HR Coordinator, VP of Operations, and the Chief Financial Officer on February 16, 2024, at approximately 3:00 P.M. confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based upon review of agency policy, accepted nursing practice, observation of agency staff during home visits, and interview with agency staff, employees failed to follow basic infection control practices for one (1) of three (3) observations (OBS). (OBS # 2). Findings include: Review of agency Policy #IC-8.0 “Clinical Bag Technique” on February 20, 2024, at approximately 3:30 P.M. stated, “Procedure: 5. Remove needed items from bag and place on a clean barrier. Clean each reusable item prior to use on the next patient. 6. Decontaminate hands prior to re-entering bag for any reason. 7. Following care: clean, reusable items (for example, blood pressure cuff, etc.) are returned to the bag…” Review of agency policy #IC-2.0 “Standard Precautions” on February 20, 2024, at approximately 3:40 P.M. stated, “Procedure: 2. B. Hands and other skin surfaces should always be washed immediately before and after patient contact, after any contact with bodily fluids and after removing gloves…” Observations of patient care during a home visits conducted on February 14, 2024, from approximately 2:35 P.M. to 3:15 P.M., and February 15, 2024, from approximately 11:00 A.M. to 2:00 P.M. revealed the following: OBS #2 on February 15, 2024, at approximately 11:10 A.M., Employee (EMP) #6, a licensed practical nurse (LPN) was observed providing care to patient #2. The LPN was venting (releasing air from) the G-tube (tube inserted through the abdomen into the stomach). The LPN was not wearing gloves for the procedure. The LPN disconnected the syringe used to vent the G-tube and repositioned patient #2 in the bed. The LPN walked to the other side of the bed and connected the G-tube feeding tube to the G-tube extension tubing. The LPN did not perform hand hygiene or don gloves during these procedures. The registered nurse (RN) set up the nursing bag on a barrier and performed hand washing but did not don gloves. The RN removed the pulse oximeter (measures oxygen in the blood) and measured patient #2’s oxygen saturation, then placed the pulse oximeter back into the bag. The RN also used the blood pressure monitor and stethoscope, placing each back into the bag after use. The RN did not decontaminate the equipment after use. The RN did not perform hand hygiene prior to re-entering the bag. An interview with the Director of Nursing, HR Coordinator, VP of Operations, and the Chief Financial Officer on February 16, 2024, at approximately 3:00 P.M. confirmed the above findings.

Based on the findings of an onsite unannounced home health agency state re-licensure survey conducted on March 1, 2021 through March 2, 2021, Criticare Home and Nursing Services, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted on March 1, 2021 through March 2, 2021, Criticare Home and Nursing Services, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 upon clinical record (CR) review, policy and procedure review, and an interview with the agency administrator, it was determined the agency failed to ensure the initial assessment visit be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician ordered start of care date for four (4) out of ten (10) clinical records reviewed (CR#2, CR#5, CR#6, and CR#9). Findings include: Review of policy " Referral, Intake Process and Assessment Visit " on 3/2/21 at approximately 1:00 PM, states " ....B. The initial assessment visit is completed: i. Within 48 hours of referral or ii. Within 48 hours of patient ' s return to home or iii. On the physician ordered start of care iv. Upon patient request outside of the above specified time frame, with documentation in the clinical record that the patient made such a request and the physician so approved. V. The patient is informed of any delay in the start of care, and they are informed when they will be admitted to care .... " Review of CR#2 (Start of care (SOC): 9/28/20) on 3/2/21 at approximately 10:30 AM revealed a referral date of 9/25/20. The initial assessment visit was completed seventy two (72) hours after the referral. There was no physician's order present in the record regarding the delay in start of care. Review of CR#5 (SOC: 9/01/2020) on 3/02/2021 at approximately 11:00 AM revealed a referral date of 8/28/2020. The initial assessment visit was completed ninety six (96) hours after the referral. There was no physician's order present in the record regarding the delay in start of care. Review of CR#6 (SOC: 5/22/2020) on 3/02/2021 at approximately 11:30 AM revealed a referral date of 5/19/2020. The initial assessment visit was completed seventy two (72) hours after the referral. There was no physician's order present in the record regarding the delay in start of care. Review of CR#9 (SOC: 12/29/2020) on 3/02/2021 at approximately 12:00 PM revealed a referral date of 12/22/2020 with a facility discharge date of 12/24/2020. The initial assessment visit was completed one hundred sixty eight (168) hours after the referral. There was no physician's order present in the record regarding the delay in start of care. An interview with the agency Clinical Manager on 3/02/2021 at approximately 12:30 PM confirmed the above findings.