Every finding on record at Home Health Professionals Inc

On 10/07/24 at 1:45 PM, an entrance conference was conducted with Agency Representatives. The agency was informed the purpose of the visit was to conduct a Medicare recertification survey for compliance with the Conditions of Participation for Home Health. The general nature of the survey process and expected length of survey were explained. On 10/11/24 at 10:30 AM, an exit survey was conducted with Agency Representatives. Preliminary findings of the survey were discussed. The Agency Representatives were given the opportunity to present additional information for the findings discussed. Additional information presented.

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 pre-survey review of the Agency's reports it was determined the Agency failed to encode and transmit Outcome and Assessment Information Set (OASIS) patient data within the required 30 days of the assessment completion date. This failed practice, if not corrected, could result in late submission of all assessments. Findings follow: Review of the "HHA (Home Health Agency) Error Summary by Agency Report" revealed a total of 39 assessments with error number -3330 (Record Submitted Late) for the prior calendar year, 10/01/2023-09/30/2024. An interview on 10/10/24 at 10:00 AM with Agency Personnel #2 confirmed failure to submit assessments within the required 30-day period.

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 clinical record review and staff interview, it was determined the Skilled Nurse (SN) failed to include all medications utilized by the patient on the medication list in 1 (#8) of 8 (#1-#8) clinical records reviewed. This failed practice presented a potential risk to all patients currently on census as the failure to conduct a medication review inhibited the patient's attending physician from making an informed decision regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. The findings are as follows: Review of clinical record #8 with a start of care of 12/20/23 revealed a patient with the diagnosis of Metabolic Encephalopathy. Review of a document titled PRN (as needed) Skilled Nurse (SN) Clinical Note and dated 02/10/2024 revealed documentation of " ORDERS WERE IN THE HOME FOR IV (Intravenous) THERAPY ERTAPENEM 1 GM (gram)/NS (normal saline) 100 ML (milliliters) TO BE INFUSED OVER 30 MIN (minutes) ONCE DAY." Review of a document titled "Prescriber Orders" revealed orders to "Administer ertapenem 1gm/NS 100 ml IV over 30 minutes vial Dial-A-Flo set at 200ml/hr (hour) every 24 hours for 14 days." Review of a document titled "Medication List" failed to include Ertapenem. No evidence the medication was checked for potential adverse effects, drug reactions, significant side effects or significant drug interactions. An interview on 10/11/24 at 11:00 AM with Agency Personnel #1 confirmed failure to include all medications on the patient's medication list or conduct a medication review on new medication for potential side effects or interactions.

. On 1/12/2022 at 10:15 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 1/14/2022 at 10:30 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. On 1/28/2022 requested additional information from Agency Representatives. On 2/9/2022 requested additional information from Agency Representatives.

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 clinical record review and staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications during the review of the patients medications in 5 (#1, #2, #5, #6 and #8) of 8 (#1 - #8) clinical records reviewed. This failed practice by the SN posed a risk of potential harm for all patients prescribed Oxygen by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. Review of Patient # 1 Clinical Record revealed the following: A. A patient with a diagnosis of Atherosclerotic Heart Disease. B. A document titled, "Home Health Care Certification and Plan of Care" (POC) dated 11/18/21 - 1/16/22, showed orders to "Teach Patient to use Oxygen at all times when ambulating and bathing to help prevent SOB [shortness of breath]." C. A document titled, “SN Clinical Note” dated 11/19/21, 12/15/21, 12/20/21, and 1/5/22, contained documentation of "O2 [Oxygen] Flow Rate 2L NC [2 liters per Nasal Canula]." D. A document titled "Medication Profile" (the document utilized by the Agency to list all medications the Patient is using), showed no evidence the Oxygen mentioned in the POC and SN notes was listed and assessed for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 2. Review of Patient # 2 Clinical Record revealed the following: A. A pertinent diagnosis of “Hypertensive Heart Disease with Heart Failure." B. A POC dated 12/16/21 - 2/13/22 showed orders to “educate oxygen use PRN [as needed] at 4.5 L NC when SOB [short of breath] and at night.” C. A document titled "Medication Profile" listed the medication Amiodarone (a medication used for Patients with Heart conditions). D. According to Drugs.com (a website used to check drug to drug interactions), using amiodarone and oxygen can increase the risk of adult respiratory distress syndrome (ARDS). Adult respiratory distress syndrome can cause severe shortness of breath, rapid breathing and low oxygen. E. The Medication Profile showed no evidence the Oxygen mentioned in the POC was listed and assessed for potential adverse effects, drug reactions, significant side effects or significant drug interactions including the increased risk of ARDS. 3. Review of Patient # 5 Clinical Record revealed the following: A. A pertinent diagnosis of Diastolic Congestive Heart Failure. B. A POC dated 11/15/21 - 1/13/22 showed orders to " Educate Oxygen use 2 L NC. PRN for SOB." C. A document titled "Medication Profile" showed no evidence the Oxygen mentioned in the POC was listed and assessed for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 4. Review of Patient # 6 Clinical Record revealed the following: A. A POC dated 9/22/21 - 11/20/21 showed a diagnosis of "Dependence on supplemental Oxygen." B. A document titled "SN Clinical Note" dated 9/17/21 showed documentation of "Equipment of Oxygen Concentrator, and Tank". C. A document titled "Medication Profile" showed no evidence Oxygen was listed and assessed for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 5. A review of Patient #8 Clinical Record revealed the following: A. A document titled “SN Clinical Note" dated 5/15/21 showed "02 use Nasal cannula 4 L/min for 24 hrs/day”. B. A document titled "Medication Profile" showed no evidence Oxygen was listed and assessed for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 6. During an interview on 1/14/22 at 9:00 AM, Agency Representatives were provided an opportunity to present additional documentation. Agency Personnel #2 confirmed the Agency staff did not include a review of all medications for patients #1, #2, #5, #6, and #8. Agency Personnel #1 stated there was a "computer glitch" that would not allow the Agency staff to add Oxygen to the Medication Profile for review," further verifying all medications were not reviewed for Patients #1, #2, #5, #6 and #8.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. 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. This CONDITION is not met as evidenced by: Based on Clinical Record review and staff interviews it was determined the Agency failed to deliver care and services in accordance with physician orders in 3 (#1, #5 and #7) of 8 (#1 - #8) Clinical Records reviewed, failed to obtain Physician Orders for treatment and services provided to patients in 2 (#3 and #4) of 8 (#1 - #8) Clinical Records reviewed, and failed to promptly notify the Physician of pertinent assessment findings in 5 (#1, #2, #3, #4, and #6 ) of 8 (#1 - 8) Clinical Records reviewed. These failed practices had the potential to affect the quality of care received by all patients currently on census, in that, there was a risk for adverse outcomes and the potential to affect the attainment of the patients’ individual goals and actual adverse outcomes with a potential for requiring hospitalization and/or Emergency Department visits. . 1. The agency failed to deliver care and services in accordance with Physician orders. A. Refer to G 578 for details related to the failure of the Agency to deliver care and services in accordance with Physician orders. 2. The agency failed to obtain Physician Orders for treatment and services provided to Patients. A. Refer to G 580 for details related to the failure to obtain Physician's orders. 3. The agency failed to promptly alert the physician of pertinent assessment findings and changes in patient conditions. A. Refer to G 590 for details related to the failure of the Agency to promptly alert the Physician of changes. B. G 590 is a repeat deficiency of Re-Certification Survey dated 8/3/2018. .

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Skilled Nurse (SN) did not follow the Physician orders in the Plan of Care (POC) in 3 (#1, #5, and #7) of 8 (#1 - #8) Clinical Records reviewed. This deficient practice had the potential to prevent the Physician and SN from evaluating the improvement or decline of Patients #1 #5, and #7 Medical status, and prevented the Physician from determining any needed care which could result in a decline in the Patients' condition and possible hospital admissions. 1. Review of Patient #1 Clinical Record revealed the following: A. A patient with a primary diagnosis of Atherosclerotic Heart Disease. B. A document titled "Home Health Certification and Plan of Care" (POC) dated 11/18/21 - 1/16/22 which contained orders for SN visits 1 time per week for 9 weeks and monitor vital signs for changes in the patient’s condition. C. A document titled “SN Clinical Note” dated 11/19/21 showed a significant finding of a low blood pressure reading of 97/54. Prior SN visits revealed the SN documented the Patient’s blood pressure readings dated 10/22/21 of 121/78, dated 10/27/21 of 133/77, dated 11/3/21 of 129/78, dated 11/10/21 of 120/72, and dated 11/14/21 of 118/69. D. A document titled, “SN Clinical Note” dated 12/08/21 showed the SN missed 2 visits; one on the week of 11/21/21 and one on the week of 11/28/21. The next SN visit was completed on 12/8/21. E. There was no evidence the Physician was notified of the low the blood pressure reading the SN documented on 11/19/21 and the 2 missed SN visits. 2. Review of Patient # 5 Clinical Record revealed the following: A. A primary diagnosis of Acute on Chronic Diastolic Congestive Heart Failure. B. A POC dated 11/15/21 - 1/13/22 with orders for "Clinician to assess vital signs, assess weight gain of 5 lbs. (pounds) within a few days." C. A document titled, “SN Clinical Note” dated, 11/15/21, 11/22/21, and 12/10/21 showed no evidence weights were assessed by the SN. 3. Review of Patient # 7 Clinical Record revealed the following: A. A POC dated 5/3/21 - 7/1/21 showed orders for the SN to visit 2 times per week for 9 weeks. B. A SN visit was missed for the week of 5/23/21. C. There was no evidence the Physician was notified of the missed SN visit. 4. During an interview on 1/14/22 at 9:00 AM, Agency Representatives were provided an opportunity to present additional documentation. Agency Personnel #1 and #2 confirmed the SN did not follow the Physician orders for visit frequency for Patients #1, #5 and #7

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 Clinical Records review and staff interviews, the SN failed to obtain a Physician's orders for care and treatments for 2 (#3 and #4) of 8 ( #1 - #8) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients requiring wound care, in that patients may not receive treatments as ordered by the Physician which could result in adverse outcomes. 1. Review of Patient # 3 Clinical Record revealed the following: A. A patient with a pertinent diagnosis of Chronic Diastolic Congestive Heart Failure. B. A document titled, "Home Health Care Certification and Plan of Care" (POC) dated 12/02/21 - 1/30/22 contained no orders for wound care. C. A document titled, “SN Clinical Note” dated, 12/06/21 showed, "Patient ran into the door facing and skinned left great and second toe…. The SN instructed the wife "to have the aide [Aide paid by Pt.] clean it up. Put TAO (Triple Antibiotic Ointment) on cut areas and applied gauze applying some pressure to stop the bleeding.” D. There was no evidence in the clinical record the SN obtained an order to provide wound care. E. During an interview on 1/14/22 at 9:00 A.M, Agency Personnel #2 verified the SN had not obtained physician orders to provide wound care. 2. Review of Patient # 4 Clinical Record revealed the following: A. A POC dated 11/6/21 - 1/4/22 contained no orders for wound care. B. A document titled, “SN Clinical Note” dated 12/28/21 showed, "Pt has a skin tear to LLE [left lower extremity] from trama [trauma]. Measures 2.6 cm (centimeters) X 2.1 cm X 0.1 cm, scant amount of serisang [serosanguineous] drainage, peri-wound [surrounding the wound] bruised…wound cleanse with wound cleanser, pat dry, xeroform placed over the skin tear then covered with border gauze, Dtr. [Daughter] will change daily until next SNV [Skilled Nurse Visit].” C. There was no evidence in the clinical record the SN obtained an order to provide wound care. D. During an interview on 1/14/22 at 9:00 A.M. Agency Personnel #1 and #2 verified the SN had not obtained orders from the Physician to provide wound care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview it was determined Agency staff Clinicians failed to notify the Physician when the updated Comprehensive Assessment indicated a change in condition in 5 (#1, #2, #3, #4, and #6) of 8 (#1 - #8) Clinical Records reviewed. This deficient practice had the potential to prevent the patient from receiving appropriate care and delay attainment of personal goals. These deficient practices are a repeat of survey results completed 8/3/2018. 1. Review of Patient #1 Clinical Record revealed the following: A. A patient with a primary diagnosis of "Atherosclerotic Heart Disease. B. A document titled, "Home Health Care Certification and Plan of Care" (POC) dated 11/18/21 - 1/16/22 showed orders for "S/O (skilled observation and assessment) heart failure symptoms" and to "Teach Patient/caregiver symptoms of significant heart failure to be reported immediately." C. A document titled "SN Clinical Note" dated 11/19/21 showed documentation of a blood pressure reading of 97/54. Prior SN visits revealed the SN documented the Patient’s blood pressure readings dated 10/22/21 of 121/78, dated 10/27/21 of 133/77, dated 11/3/21 of 129/78, dated 11/10/21 of 120/72, and dated 11/14/21 of 118/69. D. There was no evidence the Physician was notified of the low blood pressure reading. 2. Review of Patient #2 Clinical Record revealed the following: A. A pertinent diagnosis of "Pressure Ulcers of right and left buttocks stage 2” (A break in the top 2 layers of the skin). B. A POC dated 12/16/21 - 2/13/22 showed orders for the "Clinician to assess Pain…." C. The Agency used a pain scale of 0 – 10, with 10 being the worst pain. D. A document titled, “SN Clinical Note” showed SN visits dated 12/15/21, 12/22/21 and 1/5/22. The SN documented the patient had pain in their buttocks on 12/15/21 at 8/10, on 12/22/21 at 9/10, and 1/5/22 at 8/10. E. There was no evidence in the Clinical Record the SN reported the Patient’s pain to the Physician. 3. Review of Patient #3 Clinical Record revealed the following: A. A pertinent diagnosis of Congestive Heart Failure. B. A POC dated 12/2/21 - 1/30/22 showed orders for weekly SN visits. C. A document titled, “SN Clinical Note” dated 12/06/21, 12/13/21,12/27/21, showed the SN documented Lung sounds, “Clear in all fields.” D. A document titled, “SN Clinical Note” dated 1/10/22 showed the SN documented lung sounds with "crackles on auscultation (listening to the lung sounds)." E. There was no evidence the SN notified the Physician of the change in patient’s condition regarding the Patient’s lungs sounds. F. A document titled, “SN Clinical Note” dated 12/6/21 showed the Agency staff was notified by Patient’s spouse the patient had "ran into the door facing and skinned left great toe and second toe.” G. There was no evidence the SN notified the Physician of the Patient’s injury to toes. 4. Review of Patient #4 Clinical Record revealed the following: A. A document titled "SN Clinical Note" dated 11/10/21 showed "Pt. [Patient] said fell on Sunday and bruised right side. Pt. said sore but denied increased SOB [shortness of breath]." B. A document titled, “SN Clinical Note” dated 11/18/21 showed "Pt said still sore on right side." C. A document titled, “SN Clinical Note” dated 12/28/21 showed "Pt. has a skin tear to LLE (left lower extremity) from trauma [patient’s fall dated 11/07/21 per SN Clinical Note dated 11/10/21]." D. There was no evidence the SN notified the Physician of changes in the patient’s condition including the patient’s fall and traumatic skin tear. 5. Review of Patient #6 Clinical Record revealed the following: A. A patient with a primary diagnosis of “Malignant neoplasm of left ureter” [Cancer of the urinary system]. B. A POC dated 7/24/21 - 9/21/21 showed orders for "Clinician to assess pain, educate patient management, including rest, comfort, positioning, and pain medication." C. A document titled “SN Clinical Note” dated 7/30/21 showed the patient's pain at 8, dated 8/18/21 showed the patient’s pain at 8 and "Patient stated he can hardly use his left leg," and dated 9/17/21 showed the patient’s pain at 8. D. The Agency uses the 0 – 10 pain scale with 10 being the most pain. E. There was no evidence the Physician was notified of the patient's changes in condition including pain and inability to move left leg independently. 6. During an interview on 1/14/22 at 9:00 AM, Agency Representatives were provided an opportunity to present additional documentation. Agency Personnel #1 and #2 verified the Physician was not notified of Patient's #1, #2, #3, #4, and #6 significant changes in condition.