Every finding on record at Faith Home Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 10/5/23. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number E = Employee AM = morning AV = Arteriovenous fistula SN = Skilled Nurse POC = Plan of care SOC = Start of care NS = Normal Saline ABD = Abdominal Pads PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy LPN = Licensed Practical Nurse OT = Occupational Therapy CMS = Centers for Medicare and Medicaid Services

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 review of clinical records and staff interviews, it was determined the Agency failed to ensure informed consents included the frequency of visits for the services to be provided. This was found in 3 of 7 (Pts. # 3, 4 and 5) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 10/2/23 and 10/3/23 between 2:00 PM to 4:00 PM: Pt. #3. SOC: 01/12/23. Pt. received SN, PT and OT services. Pt. #4. SOC: 09/12/23. Pt. received SN, PT and OT services. Pt. #5. SOC: 05/19/23. Pt. received SN service. The records lacked documentation that the Pt. or Pt.’s representative was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. During staff interviews with the Administrator, Director of Nursing, Alternate Director of Nursing and Office Manager on 10/4/23 between 1:30 PM and 2:40 PM it was confirmed the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits and staff interviews, it was determined the Agency failed to provide Pts. the State hotline and/or any contact information. This was found in 3 of 3 (Pts. #1, 2 and 3) home visits conducted. Findings include: 1. The Agency's Admission Folder was reviewed on 10/2/23. The folder lacked complete contact information regarding need to file/submit a complaint with the State. 2. The following home visits were conducted on 10/3/23 from 9:30 AM to 12:30 PM: Pt. #1. SOC 09/21/23 Pt. #2. SOC 09/21/23 Pt. #3. SOC 01/12/23. During the home visits, the Pt. admission folders were reviewed and lacked the information to which the Pt. or Pt.’s representative may file a complaint with the State. 3. During staff interviews with the Administrator, Director of Nursing, Alternate Director of Nursing and Office Manager on 10/4/23 at 1:15 PM, it was stated the same admission folder is given to all Pts. and the folder lacked the information to file a complaint with the State. The administrative staff also 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 clinical record review, Policy review and staff interviews, it was determined that the Agency failed to ensure Plans of Care included all the requirements. This was found in 2 of 2 (Pts. #1 and 6) clinical records reviewed wherein Pts. were receiving dialysis treatment. Findings include: 1. Pt. #1 was admitted for home health services on 9/21/23 with the Principal Diagnosis of Encounter for Surgical Aftercare following Surgery on the Skin and Subcutaneous. Pt. #1’s clinical record included an initial comprehensive assessment which indicated that Pt. #1 has a hemodialysis access and is diagnosed with End Stage Renal Disease, Dependence on Hemodialysis and Congestive Heart Failure. The POC for the certification period of 9/21/23 to 11/19/23 lacked interventions for the hemodialysis access site and lacked parameters for reporting weight changes to the physician. 2. Pt. # 6 was admitted for home health services on 8/5/22 with a Principal Diagnosis of Non-pressure Chronic Ulcer Unspecified Part of Left Lower Leg with Unspecified Severity. Pt. #6’s clinical record included an initial comprehensive assessment which indicated that Pt. #6 has a hemodialysis access/ AV fistula on the left forearm and is diagnosed with End Stage Renal Failure, Dependence on Hemodialysis and Chronic Combined Systolic and Diastolic Heart Failure/ Congestive Heart Failure. The POC for the certification period of 8/5/22 to 10/13/23 lacked interventions for the hemodialysis access and lacked parameters for reporting weight changes to the physician. 3. The Agency Policy titled “Plan of Care – CMS #485 and Physician /Practitioners Orders” was reviewed on 10/4/23 and required, “Each patient must receive an individualized plan of care…The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment…The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.” 4. During an interview with the Administrator, the Director of Nursing, the Alternate Director of Nursing and Office Manager on 10/4/23 at 2:30 PM, 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 observation during a home visit, review of the clinical record, Policy review and staff interviews, it was determined the Agency failed to ensure that the wound treatment provided was ordered by the Physician. This was found in 1 of 4 (Pt. # 1) Pts. who were receiving wound care. Findings include: 1.Pt. #1 was admitted for skilled home health on 09/21/23 with a Principal Diagnosis of Encounter for Surgical Aftercare Following Surgery of the Skin and Subcutaneous. During a home visit, the LPN (E#2) on 10/3/23 performed wound care. E#2 cleansed the right breast area with NS, pat it dry with gauze, applied cream and applied a strip of calcium alginate underneath the right breast. E#2 then cleansed the left breast area with NS, pat it dry with gauze, applied cream and applied a strip of calcium alginate dressing underneath the left breast. Pt. #1’s clinical record was reviewed on 10/3/23. The record included a Plan of Care for the period of 09/21/23 to 11/19/23 requiring: “SN to perform wound care to the right breast. Cleanse with NS, apply gauze, cover and secure with ABD pads using aseptic technique…SN to perform wound care to left breast. Cleanse wound with NS, apply gauze, cover, and secure with ABD pads, using aseptic technique…” There were no changes in wound orders on the clinical record. The record lacked a physician order for the wound treatment using calcium alginate. 2.The Agency policy “Physician/Practitioner Orders – Verbal Orders” was reviewed on 10/4/23 and required, “Drugs and treatments are administered by Agency staff only as ordered by the Physician.” 3. During an interview with the Administrator, Director of Nursing, the Alternate Director of Nursing and Office Manager on 10/4/23 at 2:20 PM, the above finding was confirmed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on a review of clinical records, policy review and staff interview, it was determined the Agency failed to ensure that documentation in the clinical record was accurate. This was found in 2 of 7 (Pts. #6 and #7) clinical records reviewed. Findings include: 1. Pt. # 6 was admitted for home health services on 8/5/22 with a Principal Diagnosis of Non-pressure Chronic Ulcer Unspecified Part of Left Lower Leg with Unspecified Severity. Pt. #6’s LPN Visit Notes dated 8/8/23, 8/15/22, 8/18/22 included the following documentation: Wound #5 Distal, Dorsal Left Middle Venous Stasis Ulcer… Length: 4 cm, Width: 0.5 cm, Depth: 0.2 cm Wound Score: 6, Surface Area: 2 cm2. The LPN Visit Notes dated 8/18/22, 8/22/22, 8/27/22 and 8/31/22 included the following documentation: Wound #5 Distal, Dorsal Left Middle Venous Stasis Ulcer… Length: 4 cm, Width: 5 cm, Depth: 0.2 cm Wound Score: 11, Surface Area: 20 cm2. The measurement in the clinical record indicated a decline in the wound status. During an interview with the Director of Nursing and Alternate Director of Nursing on 10/4/23 at 2:15 PM, it was confirmed that the measurement documented for the width of the wound on the notes dated 8/18/22, 8/22/22, 8/27/22 and 8/31/22 were incorrect and that it should have been documented accurately. 2. Pt. #7 was admitted for home health services on 6/17/23 with the Principal Diagnosis of Gastric Ulcer Unspecified as Chronic or Acute Without Perforation. Pt. #7’s initial comprehensive assessment was reviewed. The assessment indicated that Pt. #7’s cognitive status was oriented x 3 “Alert to Person, Time and Place.” The assessment item “C0100 Should brief interview for mental status be conducted” had the answer “No (patient is rarely/never understood).” The assessment was inaccurate. 3. The Policy "Initial Assessments/Comprehensive Assessments" was reviewed on 10/5/23 and required, "Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievement of desired outcomes..." 4. An interview was conducted with the Administrator, Director of Nursing, the Alternate Director of Nursing and Office Manager on 10/4/23 at 2:20 PM. The Director of Nursing and Alternate Director of Nursing stated that staff should document accurately. During the same interview, the above findings were confirmed.

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 a home visit observation, review of clinical records and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 4 of 7 (Pts. #1, 2, 3 and 5) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 10/2/23 at 2:00 PM to 10/3/23 at 4:00PM: Pt. #1 – SOC 9/21/23 Pt. # 2 – SOC 9/21/23 Pt. # 3 - SOC 1/12/23 Pt. #5 – SOC 5/19/23 The above-mentioned records contained the “Notice of Medicare Non-Coverage document. The section of the document. “The Effective Date of Coverage” was left blank. The documents were signed and dated by the Pts. during the SOC. The above-mentioned records also contained the document “Beneficiary Elected Transfer” which were signed and dated by the Pts. during the SOC but the sections on Medicare Payment effective, episode dates, name of initial home health agency were left blank. 2. During an interview with the Administrator, Director of Nursing, Alternate Director of Nursing and Office Manager on 10/4/23 from 12:30 PM to 2:40 PM, it was stated that the documents should be filled out appropriately. During the same interview, the above finding was confirmed.