Every finding on record at Classic Healthcare Services, LLC

Substantial Allegation Survey Substantial Allegation OH00124362 The following deficiencies are based upon substantial allegation OH00124362 completed on 09/14/21. Classic Healthcare Services, LLC 368314, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to inform the patient of any changes in the care provided for one of two patient medical records reviewed (Patient #3). The agency census was one. Findings include: Review of the undated policy and procedure titled Discharge Criteria and Process revealed when the patient's plan of care changes and that change results in discharge or reduction of services, the patient or his/her representative, as well as his/her primary physician, will be notified and involved in planning decisions. Review of Patient #3's medical record revealed a physician order dated 06/24/21 which indicated the agency would no longer be providing home health services for Patient #3 as of 07/01/21. The documentation revealed the patient had been made aware of the change. The patient would continue to receive physical therapy until 08/01/21. Review of the medical record revealed no documented evidence the agency staff communicated the discharge with the patient in writing or verbally. Interview with Staff D on 09/14/21 at 9:26 AM revealed he/she called and talked to the patient about discharging the patient from services but had not documented the communication or sent the patient a letter of discharge. This deficiency substantiates Substantial Allegation OH00124362 (28036).

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to update the comprehensive assessment at discharge for one of three medical records reviewed (Patient #3). The facility census was one. Findings include: Review of the medical record for Patient #3 revealed the patient was admitted to the agency on 10/09/20 with the primary diagnosis of unspecified diastolic heart failure. Review of the certification period dated 06/06/21 through 08/04/21 revealed physician orders for skilled nursing services once a week for 9 weeks and home health aide (HHA) services up to 21 hours per week for nine weeks. Review of the physician order dated 06/24/21 revealed the agency would no longer be providing home health services for Patient #3 as of 07/01/21. The patient had been made aware of the change and would continue with physical therapy until 08/01/21. Review of the medical record revealed the agency staff had not completed a discharge comprehensive assessment or summary of discharge for the patient upon discharge. Interview with Staff D on 09/14/21 at 9:57 AM 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 medical record review, staff interview, and policy review, the agency failed to ensure the frequency and duration of visits to be made was provided on the plan of care for one of three medical records reviewed (Patient #3). The agency census was one. Findings include: Review of the undated policy and procedure titled Plan of Care revealed the plan of care should be completed in full to include type, frequency, and duration of all visits/services. Review of the medical record for Patient #3 revealed the patient was admitted to the agency on 10/09/20 with the primary diagnosis of unspecified diastolic heart failure. Review of the certification period dated 06/06/21 through 08/04/21 revealed physician orders for skilled nursing services once a week for 9 weeks and home health aide (HHA) services up to 21 hours per week for nine weeks. The order did not include the frequency and duration of HHA services to be provided. Interview with Staff D on 09/14/21 at 9:57 AM confirmed the plan of care had not reflected the frequency and duration of HHA services which were being provided weekly.

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 medical record review and staff interview, the agency failed to ensure treatments were administered only as ordered by a physician or allowed practitioner for one of three medical records reviewed (Patient #3). The facility census was one. Findings include: Review of Patient #3’s medical record revealed physical therapy was providing services for the patient once a week. Review of the Service Update Report dated 06/23/21 and 07/19/21 revealed the patient would receive physical therapy once a week which was not signed by the physician. Review of the physician ordered plan of care for the certification period dated 06/06/21 through 08/04/21 revealed no order for the patient to have physical therapy services. Interview with Staff D on 09/14/21 at 9:57 AM confirmed the above findings. Staff D revealed the agency failed to ensure the patient had signed orders for physical therapy.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure written care instructions were prepared for the home health aide by a registered nurse for one of three medical records review (Patient #3). The agency census was one. Findings include: Review of Patient #3’s home health aide (HHA) plan of care revealed the nurse reviewed the plan of care when they completed the patient’s comprehensive assessment on 10/09/20, 12/07/20, 02/05/21, and 04/06/21. There was no evidence the nurse reviewed the HHA plan of care when they completed the patient’s comprehensive assessment on 06/05/21. Interview with Staff D on 09/14/21 at 10:10 AM confirmed the HHA plan of care was not reviewed on 06/05/21.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to provide home health aide (HHA) services that were ordered by the physician and included in the plan of care for one of three medical records reviewed (Patient #3). The agency census was one. Findings include: Review of Patient #3’s home health aide (HHA) plan of care revealed the HHA was to perform making the bed and shampooing the patient’s hair three times a week and as needed. The HHA was to assist the patient with skin care, dressing, oral hygiene, shower, preparing for bed, meal preparation, meal set-up, encouraging fluids, assist with eating, assist with bedpan/commode, and incontinence care daily. Review of the patient’s HHA time sheets any of the above tasks were performed on 06/07/21, 06/09/21, 06/11/21, 06/14/21, 06/16/21, 06/18/21, 06/21/21, 06/23/21, 06/25/21, 06/28/21, and 06/30/21. Interview with Staff D on 09/14/21 at 10:10 AM confirmed that the HHA had not marked any of the tasks completed.

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based on the emergency preparedness survey completed 02/11/21.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to develop procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences for seven of seven patients reviewed (Patient #1, #2, #3, #4, #5, #6, and #7). This had the potential to affect all patients receiving services from the agency. The census was 93 patients. Findings include: Review of the agency's emergency preparedness plan was completed on 02/11/21. Under emergency supervisor tasks, a task for the emergency supervisors was to classify patients by priority. There were three classifications: high, wherein patients needed uninterrupted services; moderate, wherein patients care could be postponed without harm; and low, wherein the patient could safely miss a scheduled visit. Review of the classification system did not reveal to what degree patient mobility determined what classification the patient was placed in to. Review of the plans of care for Patient #1, #2, #3, #4, #5, #6, and #7 did not reveal what their priority was. On 02/11/21 at 11:25 AM in an interview, Staff A confirmed the classification system did not take the mobility of patients into account when determining their emergency preparedness classification. On 02/11/21 at 11:30 AM Staff B explained the patients' placement into a priority classification was communicated by a dot on the spine of their chart, specifically, red, blue and yellow, with red being the highest and blue the lowest. Further review of the emergency preparedness plan did not reveal any discussion on the dots on the spines of patients' charts or what they signified. Review of Patient #5's clinical record did not reveal any dot on the spine of the medical record. On 02/11/21 at 11:45 AM in an interview, Staff B confirmed Patient #5's clinical record did not have a dot.

Extended Recertification Survey COVID-19 Focused Infection Control Survey The following deficiencies are based on the extended recertification survey completed 02/11/21. Classic Healthcare Services 368314, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. At the time of the Extended Recertification Survey, a COVID-19 Focused Infection Control Survey was also completed with no deficiencies. Classic Healthcare Services is precluded from providing its own home health aide training and competency testing or competency evaluation program for a period of two years from the exit date of this survey.

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 interview and medical record review, the agency failed to ensure a review of all medications the patient was currently using was conducted for one of seven patients reviewed (Patient #5). This could affect all patients receiving services from the agency. The census was 93 patients. Findings include: The medical record review for Patient #5 was completed on 02/11/21. The patient was admitted to the agency on 04/11/17 with diagnoses including asthma, stroke, and right sided paresis. Review of the physician ordered plan of care for the certification period starting 01/20/21 revealed orders for daily skilled nurse visits and to assess for the patient's compliance, and response and safety with medications. On 02/10/21 at 11:45 AM a home visit was conducted with Staff D. During the home visit, the patient's medication bottles were reviewed with Staff D. The review revealed the patient was taking Zofran, 4 milligrams, eight hours a day as needed (filled 09/28/2020), and trazadone, 50 milligrams, as needed at bedtime (filled 12/16/2020). Review of the patient's medication profile was completed on 02/11/21. The review revealed the patient's medications were reviewed on 01/20/21, and the patient was taking one tablet of Zofran as needed for sleep and trazadone was scheduled, not as needed, at bedtime for sleep. On 02/11/21 at 9:15 AM in an interview, Staff A confirmed the medication profile did not reflect how the patient took the medications in the home.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure skilled professionals provided services as written in the plan of care (G710). The facility failed to ensure skilled professionals prepared clinical notes (G716). The cumulative effect of these systemic practices resulted in the agency's inability to ensure patients' nursing needs would be met.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure skilled professionals provided services as written in the plan of care for one of seven patients reviewed (Patient #7). This could affect all patients receiving services from the agency. The census was 93 patients. Findings include: The medical record review for Patient #7 was completed on 02/11/21. The patient was admitted to the agency on 08/23/17 with diagnoses including quadriplegia, multiple sclerosis, hypertension, unstageable pressure ulcers, and type two diabetes mellitus. The medical record review for the certification period beginning 04/09/2020 included orders for daily skilled nurse visits to provide "wound care on several pressure ulcers" and to measure wounds weekly and observe their healing status. A resumption of care Outcome and Assessment Information Set dated 04/05/2020 listed four wounds: on the right hip a 7 centimeter (cm) long by 3.5 cm wide by 1 cm deep wound, on the right ankle a 3.5 cm long by 3 cm wide wound, on the left knee a 2 cm long by 1 cm wide wound, and on the left ankle a 3.5 cm long by 3 cm wide by 1 cm deep wound. The medical record review revealed hospital discharge orders dated 04/05/2020 that stated for the left hip, left knee, and left shin to be cleansed with vashe (wound cleanser), and covered with mepilex ag (antimicrobial absorbent dressing). The discharge orders stated for the right hip, right lateral ankle left medial foot, and left lateral ankle to be cleansed with vashe, lightly packed with vashe moistened kerlix, and covered with mepilex. The medical record review revealed a skilled nurse visit note dated 04/28/2020 that stated, "Called the doctor's office about the right hip wound getting bigger. Advised to have a doctor's visit. Guardian notified." The note did not indicate how big the wound was or what it looked like. The medical record review revealed from 05/01/2020 to 05/25/2020 there were no wound measurements or wound descriptions documented. The medical record review revealed the left and right hips and left and right lateral ankles were washed with vashe and all were packed with vashe moistened kerlix and covered with mepilex dressing. The medical record review revealed a skilled nurse visit note dated 05/18/2020 that stated, "Called the doctor's office about patient's wounds." There was no documentation regarding the content of the call, wound measurement or wound description. A transfer Outcome and Assessment Information Set listed 05/26/2020 as the last date of the most recent home visit, and stated the patient went to the emergency room for "wound infection or deterioration." The medical record review revealed a recertification Outcome and Assessment Information Set dated 06/07/2020 that stated, "Patient now hospice." A phyisician ordered plan of care for the certification period beginning 06/08/2020 stated the patient "is now under (local) hospice care." The plan of care continued to direct the agency to provide home health aide services. The medical record review revealed on 07/02/2020 the patient died. On 02/10/21 at 10:22 AM in an interview, Staff A confirmed wound care provided did not match what was ordered on the plan of care and that the wounds were not measured weekly as ordered.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and medical record review, the agency failed to ensure skilled professionals prepared clinical notes for one of seven patients reviewed (Patient #1). The census was 93 patients. Findings include: The medical record review for Patient #1 was completed on 02/11/21. The patient was admitted to the agency on 03/11/16 with diagnoses including hidradenitis suppurativa (a chronic skin condition with lumps in the groin and axillae), type two diabetes mellitus, and hypertension. Review of the physician ordered plan of care for the certification period beginning 12/15/2020 revealed orders for skilled nurse visits three times a day for wound care without a description of what that entailed. The medical record review revealed a recertification Outcome and Assessment Information Set for the certification period beginning 12/13/2020 that stated the patient had two skin ulcers: one under the right breast, and one on the right groin. The assessment did not provide any measurement of the wounds, but did state they were draining serosanguinous fluid with scant amounts at the groin and moderate amounts under the breast. The medical record review of the skilled nurse visits from 01/01/21 to 01/30/21 did not reveal any measurements or descriptions of the wounds during the skilled nurse visits. With the exception of 01/01/21 at 2:00 PM, 01/02/21 at 9:50 PM, 01/06/21 at 12:00 PM, 01/08/21 at 12:00 PM, 01/10/21 at 5:00 PM, 01/12/21 at 6:00 PM, 01/13/21 at 12:00 PM, 01/17/21 at 5:00 PM, 01/14/21 at 10:00 PM, 01/18/21 at 9:00 PM, 01/20/21 at 7:50 AM, and 01/24/21 at 2:00 PM, wound care was given, though what kind of wound care was given was not documented. The medical record review revealed the patient had pain at each visit denoted by a tick mark next to a line item for location and intensity in the pain section of the skilled nurse visit note. The review did not reveal where, what type of pain the patient was experiencing, or how intense (on a scale of zero to ten) the pain was. On 02/10/21 at 2:55 PM in an interview, Staff A confirmed the skilled nurse visit notes did not say wound care was done on the aforementioned dates, and when wound care was performed the skilled nurse visit notes did not say what type of care was provided. She confirmed the notes did not say where the patient was having pain, what type of pain the patient had, or how bad it was.