Every finding on record at Homecare Maryland, LLC

A recertification survey of HomeCare Maryland, Inc was conducted January 8-13, 2025. After the review of the agency's emergency preparedness program and plan, the agency was found in compliance with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

A standard-level home health agency re-certification survey in conjunction with a Maryland state re-licensure survey was conducted at HomeCare Maryland, Inc on January 8-13, 2025. The survey included the following: a review of clinical records, administrative records, and interviews with the agency's staff. The agency's emergency preparedness program and plan were reviewed. Five home visit observations were conducted during the survey. One initial nursing start of care, one occupational therapy evaluation, two routine skilled nursing visits, and one routine physical therapy visit. A total of seventeen randomly selected patient records were reviewed during the survey. The scope of services included the following: Skilled Nursing Services – Sixteen Physical Therapy Services – Fourteen Occupational Therapy Services - Ten Medical Social Worker - Two Home Health Aide Services – Three Speech-Language Services - Two Findings in this report were based on data present in the clinical record at the time of the reviews. The agency's administrative and clinical staff were kept informed of the survey findings as the survey progressed. The agency's staff were given the opportunity to present information relative to the findings during the course of the survey. The exit conference was conducted with agency personnel on January 13, 2025. The findings of the Medicare re-certification survey were reviewed, and a signed plan of correction verification form were provided to the agency's administrator.

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 record review and interview with AD, the agency failed to transmit completed OASIS assessments to the CMS system within 30 days of completing initial assessments, as required by regulation 484.45(a). This failure to adhere to the required time frame for OASIS transmission has the potential to compromise the accuracy and timeliness of data reporting and impact compliance with federal regulations. Review of the agency’s Error Summary Report for the period of 1/1/24 through 1/6/25 revealed error #3330 with one hundred twelve (112) records being transmitted beyond the 30-day requirement time frame.

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 on review of patient records and interviews with agency staff, the agency staff did not communicate delays in care for 2 out of 17 patients placing the patients at risk for adverse or negative health care outcomes. Patients: #4 and #13 Findings included: The home health agency furnishing services must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients plan of care. 1.All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records on 1/13/25. During record review on 1/13/25, Patient number four had an order for Occupational Therapy (OT) was dated 1/5/25; the OT evaluation had not been completed as of 1/13/25. When asked the agency staff had no further documentation or explanation for the delay in care. During record review on 1/13/25 for patient number thirteen, a referral for care was accepted by the agency on 9/24/24. Patient admission to the agency was scheduled for 9/27/24. The admission was rescheduled to 9/29/24 due to the patient’s doctor’s appointment on 9/27/24. There was no documentation noting why the admission did not occur on 9/29/24. Patient thirteen was noted as admitted to the agency on 10/3/24. There was no documentation for the care delay from 9/29/24-10/3/24. When asked the agency staff had no further documentation or explanation for the delay in care.

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 on observation during a home visit with agency clinical staff, the clinical supervisor and the Registered Nurse (RN) clinician, adequate infection control prevention was not implemented during the provision of wound care. The RN failed to demonstrate adequate infection control practices. Failure to adhere to infection control standards placed patients at risk for infection. Patient: 16 Employee: 2 Findings included: Infection prevention practices require the separation between dirty (contaminated: covered with disease-causing organisms) and clean (reduced level of contamination) tasks and areas during a dressing change an invasive procedure to prevent the transmission (cross-contamination) of bacteria/viruses, which can lead to infection. It means that hands must be washed or sanitized in addition to glove changes between dirty (for example, removing a soiled dressing, cleansing a wound, removing used clinical supplies, cleansing before an invasive procedure and touching a cellular telephone). Clean procedures (for example, inserting a urinary catheter applying new dressing materials or handling new clinical supplies, including medications). Additionally, every attempt should be made to avoid the contamination of sterile (free of bacteria) or clean items. The regulation for standard infection prevention states that the home health agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This did not occur. During the care visit, on 1/9/25, with patient #16, the RN performed wound care to the patient right heel. The Employee #2 RN gathered and laid the wound care dressing and bandage supplies on a barrier, the patient’s affected part was placed on a barrier, the wound cleanser and paper measuring tape were placed on the floor with no barrier, and a trash bag was placed within reach of the RN. The RN cleansed and treated the wound as ordered; however, when measuring the wound the RN used the contaminated paper measuring tape (that had been placed directly on the floor) to measure the open wound. During the interview on 1/9/25, the clinical supervisor acknowledged the breaches in universal precautions.

A complaint investigation was concluded of Homecare of Maryland on November 5, 2021. The agency provides home health care services. Complaint number: MD00172348 The complaint included one allegation - quality of care/treatment The complaint was substantiated. The investigation included an interview of the agency’s Administrator via telephone and a review of the patient's clinical record and administrative documents. Findings in this report are based on data present in the patient clinical records at the time of review. The Administrator was kept informed of the investigative findings. The Administrator was allowed to submit for review information relative to the findings during the investigation.

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 a review of the agency's policies and procedures, review of the patient's clinical record, and interview with the agency's administrative staff, the agency's skilled nursing staff (SNs), failed to proactively (create and control to cause something to happen, rather than wait) and effectively coordinate (bring different pieces together to ensure quality or effectiveness). Failure to do so placed this patient at risk for un-effective wound care management and adverse/poor healthcare outcomes, as well as other patients the agency is providing the same type of services. The findings include: The agency's SNs are responsible for coordinating the patient care, including ensuring appropriate orders are received, communicating updates/status changes in the patient's condition to the physicians responsible for the patient's care, assessing patient needs and making referrals for needed services, and including responding to changes in the patient needs. 1. A review of the patient's clinical record revealed on 7/8/2021, the patient's physician assessed the patient needed "aggressive wound care." 2. The patient was admitted to the agency on 7/16/2021, with a diagnosis of left heel pressure ulcer (unstageable), left buttock pressure ulcer, and peripheral vascular disease (PVD/narrowing of blood vessels that cause poor blood flow, usually the lower limbs). Poor blood flow can result in poor wound healing. He/she was incontinent of both bowel and bladder (stool and urine). He/she required assistance with all activities of daily living (bathing, dressing, transferring, and continence) except eating. The plan of care (POC) notes the wound care orders for these wounds present on admission; the left heel as cleanse wound with normal saline (solution used to cleanse wounds), apply santyl (medication to remove dead tissue from wounds), cover with sterile gauze and rolled gauze. The left buttock: cleanse with normal saline, pat dry, apply border dressing. 3. The patient's clinical record revealed on 8/6/2021 an addendum note (addition made) was made to document the patient has bilateral (on both sides of the body) heel wounds. The 8/10/2021 SN visit notes the patient had a right heel wound present on admission. The previous visit on 8/6/2021 is the 1st documentary evidence of the right heel wound. Also revealed, the only physician wound care order in the patient's clinical record is for the bilateral heel wounds, and the physician signed POC that includes an order for the patient's left buttock. On 10/21/21, during an interview with the agency's Administrator, he/she was requested to submit the entire clinical record related to this episode of care for review. (There are no other physician signed wound care orders in the patient's clinical record) 4. The clinical record review revealed for the 4th, 5th, 6th, 7th, 8th, 9th, 10th wounds that the patient developed, there is no documentary evidence to support any calls made to the physician notifying him/her of changes in the patient condition. Nor documentary evidence to support any additional physician signed wound care orders. A review of the agency's "Wound Best Practices" procedures indicate the following: If no improvement in the wound within 2 weeks, contact the provider to request/suggest a new wound care treatment." This did not occur. 5. On 10/21/2021, during an interview with the agency's Administrator, he/she was requested to provide wound care protocols for review. No protocols were submitted. A review of several nursing standards wound care protocols indicate that each wound must have specific orders. There is no documentary evidence that this occurred. 6. A referral was received for review noting the patient was admitted to the hospital for maggots present in his/her wound. A review of the patient's clinical record revealed the following: on 9/9/2021, the patient had a visit from the agency's SN, and wound care was provided. On 9/10/2021, the patient's visit to the wound care clinic noted a foot ulcer with several maggots found within the ulcer. The patient was sent to the hospital for further evaluation and treatment. On 9/10/2021, the hospital visit note confirmed the patient's wound was positive for maggots.

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 clinical record review, the agency staff failed to complete the patient visit frequencies as ordered in the plan of care (POC). The missed visits were undocumented. This placed the patient at risk for not meeting outcome goals and delays in treatment that led to poor/adverse patient outcomes. The clinical record review revealed the skilled nurse missed 2 visits during the patient’s 3rd week of care (7/25/2021), with a frequency of 3wk2. In the 4th week of care (8/1/2021), there was 1 missed visit, with a visit frequency of 2wk4. During the 7th week of care (8/22/2021), there was 1 missed visit, with a visit frequency of 2wk2. Missed visits disrupt the patient's care and should be documented in the patient’s clinical record, and that the patient's physician was notified of the missed visit. There is no documentary evidence that this occurred.

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 a review of the patient’s clinical records and interview with the agency’s Administrator, the agency’s staff failed to coordinate the patient’s care effectively. The failure to ensure effective coordination of the patient’s care placed the patient at risk for inadequate treatment, and poor health outcomes and the other patients on service with the agency were at risk. Findings included: 1. A review of the patient’s clinical record revealed the patient developed multiple new wounds since his/her admission to service on 7/16/2021 to 9/13/2021, with no documentary evidence of these changes being consistently reported to the patient’s physician. There were multiple undocumented missed nursing visits with no evidence of the patient’s physician being notified. 2. On 10/21/2021, during an interview with the agency’s Administrator, he/she was requested to provide the patient’s entire clinical record for this episode of care for review. This surveyor specifically asked for nursing notes, care coordination notes, physician orders, and wound care procedures/protocols. The additional records provided for review had no documentary evidence of notification to any physician of changes in the patient’s condition.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on a patient's clinical record review, the skilled professionals did not participate in adequate care coordination. This placed the patient at risk for poor healthcare outcomes and the other patients on the census that are receiving the same type of services. The findings include: Care coordination is vital for quality healthcare. It promotes unity in the healthcare team. It also builds resources for nurses involved in the patients' care. The clinical record review revealed for the 4th, 5th, 6th, 7th, 8th, 9th, 10th wounds that the patient developed, there is no documentary evidence to support any calls made to the physician notifying him/her of changes in the patient's condition. Nor documentary evidence to support any additional physician signed wound care orders. A review of the agency's "Wound Best Practices" procedures indicates the following: If no improvement in the wound within 2 weeks, contact the provider to request/suggest a new wound care treatment." This did not occur.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on a clinical record review and interview with the agency’s Administrator, the agency’s staff failed to assess and coordinate the patient’s care needs effectively. Findings include: The agency’s clinical staff are responsible for making appropriate referrals to other disciplines such as home health aides, occupational therapy, or social worker. 1. A clinical record review revealed, the patient was dependent (relied on others) on all activities of daily living (ADLs) except for eating. ADLs include bathing, dressing, continence (using the bathroom), and mobility (walking ability). He/she was primarily bedbound. On the 7/16/2021 nurse visit, it was noted the patient was in a heavily soiled diaper. The 9/1/2021 nurse visit notes, the patient wounds are deteriorating (becoming worse). The family indicated there is nothing they can do regarding the patient’s incontinence (lack of control of urine and stool) because it happens when everyone is asleep. There is no evidence that an offer of a home health aide occurred. 2. On 10/21/2021, during an interview with the agency’s Administrator, this surveyor asked why the patient was not offered a home health aide. The Administrator indicated from his/her understanding the family was involved in the patient’s care.