Every finding on record at Complete Home Health Care, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, 10/10/24.The Agency was in compliance with the Condition, 42 CFR 484.102 Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 10/10/24. Standard level deficiencies cited. Abbreviations: % = Percentage SN = Skilled Nurse SOC = Start of care RN = Registered Nurse PRN = as needed Pt./ Pts. = Patient/Patients MSW = Medical Social Worker OASIS = Outcome and Assessment Information Set VAD = Vascular Access Device

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 the review of the Agency's Error Summary report and Staff interview, it was determined in 5 of 661 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Finding include: 1. The Agency's Error Summary report for 10/01/23 - 09/30/24, was reviewed on 10/10/24 at 12:30 PM. The report included error # -3330 for 5 of 661 submissions. 0.76% of the reports submitted were more than 30 days after the M0090. 2. During an interview with the Administrator, on 10/10/24 at 12:50 PM, the Administrator confirmed that the error occurred.

Plan of care CFR(s): 484.60(a)(1) 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, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 3 of 7 (Pts. #3, 4 and 6) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 3. Pt. # 6 was admitted to Home Health Services on 05/30/24 with the diagnoses of: Primary Generalized (Osteo)Arthritis and Heart Failure. The clinical record was reviewed on 10/09/24. The POC effective 07/29/24 required: “Orders For Discipline and Treatment….Weigh patient at every SN visit….” The SN notes dated 07/30/24, 08/06/24, 08/13/24, 08/27/24 and 09/10/24, lacked weight assessments as ordered. 4. During interviews with the Administrator and Agency Supervisor on 10/09/24 from 1:30 PM to 2:15 PM, both confirmed the above findings. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 07/06/24 with the diagnosis of: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 10/08/24. The clinical record contained a POC dated 07/06/24, that required the SN to assess the patient’s weight, 1 time a week for 1 week,2 times a week for 1 week, 1 time a week for 1 week, 1 time q 2 week for 6 weeks and 2 PRN visits. The SN failed to visit to assess the patient's weight for week 4 and the plan of care was not modified. 2. Pt. #4 was admitted to the Home Health Services on 02/23/23 with the diagnosis of: Pressure Ulcer of Sacral Region Stage 4. The clinical record was reviewed on 10/08/24. The clinical record contained a recertification POC dated 09/25/24, that required PT to assess the patient, 1 time a week for 9 weeks. As of 10/10/24, the PT failed to assess/visit and the plan of care was not modified.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on the review of the Agency’s business cards, admission package and Staff interview, it was determined the Administrator failed to perform all of the required day to day operations. Findings include: 1. On 10/08/24 at 9:30 AM, the Administrator and Agency Supervisor, presented business cards with the incorrect Agency's address. It was stated by the Administrator and Agency Supervisor, the Agency relocated May 1, 2024. 2. The Agency's admission packet was reviewed on 10/08/24 at 9:30 AM and included a brochure, with the incorrect address and incorrectly listed the MSW and Aide services as provided. It was observed the State license did not include the MSW and Aide services. During the interview with the Administrator and Agency Supervisor, it was stated the Agency no longer provides the MSW and Aide services and the brochure was not yet updated. 3. The findings were confirmed, during the interview with the Administrator, on 10/10/24 between 1:30 PM and 2:00 PM.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 2 of 7 (Pts. # 4 and 5) clinical records reviewed, the plans of care were not updated or developed. Findings include: 1. Pt. #4 was admitted to the Home Health Services on 06/12/24 with the diagnosis of: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 10/08/24. The clinical record contained a POC dated 07/27/24 thru 09/24/24 and as of 10/09/24 lacked the POC for 09/25/24 and current ongoing care. 2. Pt. #5 was admitted to the Home Health Services on 05/30/24 with the diagnosis of: Encounter for Adjustment and management of VAD. The clinical record was reviewed on 10/08/24. The clinical record contained a POC dated 07/29/24 thru 09/26/24 and as of 10/09/24 lacked the POC for 09/27/24 and current ongoing care. 3. On 10/09/24 at 1:30 PM, during the interview with the Agency Supervisor, it was stated the SN has not yet completed the paperwork and was working to develop the plans of care. 4. The findings were confirmed, during the interviews with the Administrator and Agency Supervisor, on 10/09/24 between 1:30 PM – 2:40 PM.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and Staff interview, it was determined that in 1 of 2 (Pt. #6) discharged records reviewed, the Agency failed to ensure a discharge summary was completed and sent to the Physician. Findings include: 1. Pt. # 6 was admitted to Home Health Services on 05/30/24 with the diagnosis of: Primary Generalized (Osteo)Arthritis. The clinical record was reviewed on 10/09/24. The clinical record documented a discharge assessment dated 09/24/24. The clinical record lacked documentation that a discharge summary was completed and sent to the Physician. 2. During an interview with the Administrator and Agency Supervisor on 10/09/24 at 2:15 PM, the Administrator and Agency Supervisor confirmed the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record reviews and Staff interviews, it was determined that in 5 of 7 (Pts. #1, 2, 6, 4 and 5) clinical records reviewed, the Agency failed to ensure the clinical records were completed as required. 4. Pt. #4 was admitted to the Home Health Services on 02/23/23 with the diagnosis of: Pressure Ulcer of Sacral Region Stage 4. The clinical record was reviewed on 10/08/24. The clinical record included an incomplete Recertification note that lacked the date and signature of the clinician. 5. Pt. #5 was admitted to the Home Health Services on 05/30/24 with the diagnosis of: Encounter for Adjustment and management of VAD. The clinical record was reviewed on 10/08/24. The clinical record included an incomplete Recertification note that lacked the date and signature of the clinician. 6. The findings were confirmed with the during the interview with the Administrator and Agency Supervisor, on 10/09/24 between 1:30 PM – 2:40 PM. Findings include: 1. Pt. #1 was admitted to Home Health Services on 04/11/24 with the diagnosis of: Hepatic Encephalopathy. The clinical record was reviewed on 10/08/24. The SN note dated 09/26/24, included vital signs and a pain assessment but lacked the SN signature and completed entries to the assessments made during the visit. 2. Pt. #2 was admitted to Home Health Services on 06/12/24 with the diagnosis of: Primary Generalized (Osteo) Arthritis. The clinical record was reviewed on 10/08/24. The SN note dated 09/24/24, included vital signs but lacked the SN signature and completed entries to the assessments made during the visit. 3. Pt. # 6 was admitted to Home Health Services on 05/30/24 with the diagnosis of: Primary Generalized (Osteo)Arthritis. The clinical record was reviewed on 10/09/24. The Discharge assessment dated 09/24/24, lacked the SN signature and completed entries to the following sections related to falls, emergent care and discharge.

A recertification survey completed. Standard level deficiencies written. Abbreviations: SOC = Start of Care AM = Morning PM = Afternoon/Evening DON = Director of Nursing

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on clinical record review, policy review, and staff interview, it was determined the Agency failed to assess pneumococcal immunization status upon admission, and document as per their policy. This has the potential to affect three of seven patients (Pt. # 7, 5, and & 6) reviewed for pneumococcal vaccine screening. Findings include: 1. Pt #7 SOC: 3/321 Diagnosis: Encounter for surgical aftercare following surgery on the genitourinary system. The clinical record of Pt #7 was reviewed on 9/8/21 at 9:45 AM. The record lacked documentation of Pneumococcal vaccination status and documentation upon admission. 2. Pt. #5. SOC: 6/4/21. Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 9/7/21 at 2:35 PM. The record contained the SOC comprehensive assessment, dated 6/4/21. The assessment lacked documentation the Pt. was assessed for the status of the pneumococcal vaccine. The record did not contain any further documentation on the status of Pt. #5's pneumococcal vaccine status. 3. Pt. #6. SOC: 4/8/20. Diagnosis: Encounter for Attention to Gastrostomy. The clinical record was reviewed on 9/8/21 at 10:00 AM. The record contained the SOC comprehensive assessment, dated 4/8/20. The assessment lacked documentation the Pt. was assessed for the status of the pneumococcal vaccine. The record did not contain any further documentation on the status of Pt. #5's pneumococcal vaccine status. 4. The Agency policy titled "Immunization Policy" was reviewed on 9/8/19 at 11:00 AM. The policy required: "...Each Patient's pneumococcal immunization status will be determined upon admission...and will be documented in the clinical record..." 5. During an interview with the DON on 9/7/21 at 10:00 AM, the DON stated a Patient's pneumococcal vaccine status is assessed and documented during the SOC initial assessment. If the Pt. requests the vaccine, the Agency refers the Pt. to their Primary Physician or pharmacy for administration of this vaccine. During interviews with the Administrator and DON on 9/8/21 at 1:45 PM and 2:30 PM, the DON confirmed Pts. #7, 5, and 6 did not have documentation they were assessed during admission for the status of the pneumococcal vaccine.

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: A. Based on observations during a home visit, Agency policy review, and staff interview, it was determined the Agency failed to ensure staff provide services in accordance with the Agency's Infection Control Standards of Practice while providing home services. This was observed in 1 of 3 (Pt. #2) home visits conducted. Findings include: 1. Pt. #2. SOC date 8/13/21. Diagnosis: Primary generalized osteoarthritis. A home visit was conducted with staff #1 on 9/7/21 at 12:00 PM. During the home visit, staff #1 entered the patient’s home and placed two bags containing medical equipment and supplies on the floor without a barrier. Staff #1 then proceeded to place the blood pressure machine, stethoscope, thermometer and box of gloves and wipes on a table that was not sanitized before placing the equipment. Staff #1 failed to comply with the Agency's Infection control policy and practice. 2. The Agency's policy titled, "Bag Technique" was reviewed on 9/8/21 at 1:30 PM. The policy required, "PROCEDURE...2. The bag should be placed on a visibly clean, dry surface in the patient’s environment. If there is no visibly clean, dry surface available, place a barrier under the bag or hang it on a doorknob or the back of a heavy chair.” 3. During an interview with the Administrator and the DON on 9/8/21 at 3:45, the DON confirmed Staff #1 failed to comply with the Agency's policy relative to Infection Control.