Every finding on record at Horizon Healthcare Services, LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 107558 The following deficiencies are based upon substantial allegation 107558 completed on 07/30/24. Horizon Healthcare Services is not in compliance with the requirements found at at 42 CFR Part 484, Subpart B, C, Home Health Agencies.

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 record review and interview, the facility failed to conduct an initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patient. This affected one (Patient #72) of three patients reviewed. The facility active census was 67. Findings include: Review of Patient #72's medical record revealed a hospital discharge dated 01/23/24 and referral for home care services. Diagnoses included chronic obstructive pulmonary disease, depression, anxiety, osteoporosis, gastroesophageal reflux disease, peripheral neuropathy (bilateral upper and lower extremities), hypothyroidism, muscle spasms and a history of falls. Medical devices included wheelchair, walker, incentive spirometry, oxygen, shower chair and grab bars. Review of the insurance service authorization included the patient was to receive 15 hours of care per week, five hours each Monday, Wednesday and Friday. Provide hands on assistance with showering, dressing, transfers, medication reminder, meal preparation, laundry and errands. A Communication Note 02/02/24 dated documented Patient #72's Start of Care was not completed. Her phone number was disconnected. Due to it being past the 48 hour window and not being able to reach the patient, a new physician order was sent over on 02/01/24. They now have a working phone number for her and will start the care when a new signed physician order is sent over. There was no evidence the agency contacted the physician when the Start of Care was due or obtain an alternate phone number.. Review of the start of care assessment revealed it was completed 02/08/24 when it was due 01/25/24. The start of care date was listed as 01/25/24 and the plan of care listed the certification period of 01/25/24 to 03/24/24 when the start of care was actually completed on 02/08/24. During an interview on 07/23/24 at 2:45 P.M., Staff D verified the start of care was not completed within 48 hours of the patient being discharged from the hospital. Staff D verified there was not evidence of the facility notifying the physician.

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 record review and interview, the agency failed to ensure each patient received home health services as written in the individualized plan of care and failed to notify the physician of delayed start of care and missed visits. This affected two (Patient's #37 and #72) of three patients reviewed. This could affect all patients receiving services from the agency. The active census was 67. Findings include: 1. Review of Patient #72's medical record revealed a start of care assessment was completed 02/08/24. Diagnoses included chronic obstructive pulmonary disease, depression, anxiety, osteoporosis, gastroesophageal reflux disease, peripheral neuropathy (bilateral upper and lower extremities), hypothyroidism, muscle spasms and a history of falls. Medical devices included wheelchair, walker, incentive spirometry, oxygen, shower chair and grab bars. Review of the insurance service authorization documented the patient was to receive 15 hours of care per week, five hours each Monday, Wednesday and Friday. Provide hands on assistance with showering, dressing, transfers, medication reminder, meal preparation, laundry and errands. Review of the Home Health Certification and Plan of Care for the certification period dated 01/25/24 to 03/24/24 revealed orders for home health aide services 20 hours a week, no length period included. The service authorization was only for 15 hours. The start of care date was listed as 01/25/24 and the certification period dated 01/25/24 to 03/24/24 when the start of care was not completed until 02/08/24. The Home Health Aide was to start 02/09/24 but the patient delayed the start until 02/12/24. The home health aide (HHA) aide called off 02/12/24 so HHA services did not start until 02/13/24. There was no evidence the physician was notified of the delay in the start of care. Review of the HHA assignment/time sheets from 02/13/24 through 03/15/24 revealed no personal care services were provided. Housekeeping services were the only services checked as provided. During an interview on 07/23/24 at 2:45 P.M., Staff D verified there were no personal care services signed as provided. Staff D verified the start of care date and start of certification period of 01/25/24 was an error. The original date start of care was to be 01/25/24 but it actually was not completed until 02/08/24. Staff D verified the HHA was to start 02/09/24 but did not start until 02/13/24. She verified she had no evidence of physician notification for delay in initiation of services. Staff D further verified the 20 hours of Home Health Aide hours on the Home Health Certification and Plan of Care was an error; it should have read 15 hours a week. 2. Review of Patient #37 revealed a start of care date of 07/27/23. Diagnoses included heart failure, and peripheral vascular disease. Home health aide hours were increased to 40 hours a week 10/24/23. The patient was to have 10 hours four times a week. The certification period 11/24/23 to 01/22/24 revealed the patient was to have 40 HHA hours a week, 10 hours a day. Review of missed visit slips for 01/01/24, 01/04/24 and 01/15/24 revealed no evidence of physician notification of missed days. During an interview on 07/23/24 at 4:54 P.M. ,Staff D verified they had no evidence of physician notification for missed visits. Review of the facility's Missed Visit Documentation form included "under federal regulations all homebound health care agencies are required to inform the physician of any changes in the plan of care".

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 record review and interview, the facility failed to ensure provided services were ordered by a physician. This affected one (Patient #73) of three patients reviewed. The current active census was 67. Findings include: Record review revealed Patient #73's start of care date was 02/25/23. Diagnoses included type 2 diabetes and dementia. The plan of care for the certification period 02/25/24 to 04/24/24 included skilled nursing three times a week for 60 days. The skilled nurse was to perform blood sugar testing, instruct on insulin preparation and diabetic management. The patient was discharged from the hospital 02/23/24 and started services with the home health agency on 02/25/24. Skilled nursing was provided three times a week through 04/08/24. Review of the physician orders revealed an order was sent to the physician office 04/03/24 for the skilled services and was signed by the physician 04/10/24. Review of the discharge OASIS revealed the patient was discharged per her request 04/09/24. During an interview 07/23/24 at 6:02 P.M., Staff B verified the facility did not have a signed physician order for nursing services three times a week until after the patient was discharged. Staff B stated the patient's daughter had the order from the hospital and did not give it to the facility so she wrote a verbal order for the physician to sign.

Substantial Allegation Survey Substantial Allegation 70951 An entrance conference was conducted with administrative staff on 07/20/22, and an exit conference was completed with the administrative staff on 07/20/22. The following deficiencies are based on the Substantial Allegation Survey completed on 07/20/22., Horizon Healthcare Services, LLC 368340, is not in compliance with requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 medical record review and staff interview, the agency failed to ensure patients received services as written in the plan of care for two of three medical records reviewed (Patients # 1 and # 2). The agency census was 84. Findings include: 1). Review of the medical record for Patient #1 for the certification period dated 04/13/22 through 06/11/22 revealed diagnoses to include type two diabetes, chronic obstructive pulmonary disease, and schizoaffective disorder. The physician orders included home health aide services fifteen hours weekly to assist with activities of daily living, meals, and housekeeping. Review of the home health aide visit notes from 05/01/22 through 05/07/22 revealed only ten hours of aide services was provided. There was no evidence the physician was notified that services were not provided as ordered. Staff A confirmed the this finding in an interview on 07/20/22 at 4:47 PM. 2). Review of the medical record for Patient #2 for the certification period dated 05/21/22 through 07/19/21 revealed diagnoses to include non traumatic subdural hemorrhage, anemia, and chronic kidney disease. The physician orders included home health aide services thirteen hours weekly to assist with activities of daily living, meals, and housekeeping. Review of the home health aide visit notes revealed from 05/29/22 through 06/04/22 only two hours of aide services were provided, 06/05/22 through 06/11/22 seven hours were provided, 06/12/22 through 06/18/22 four hours were provided, 06/19/22 through 06/25/22 six hours were provided. In addition, there were no documented aide visits from 06/26/22 through 07/16/22. There was no evidence the physician was notified that services were not provided as ordered. Staff A confirmed these findings in an interview on 07/20/22 at 5:48 PM.

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 services were administered only as ordered by a physician for one of three medical records reviewed (Patient #1). The agency census was 84. Findings include: Review of the medical record for Patient #1 for the certification period dated 04/13/22 through 06/11/22 revealed diagnoses to include type two diabetes, chronic obstructive pulmonary disease, and schizoaffective disorder. Per physician orders skilled nursing services were to be provided daily (Monday through Friday) until 04/30/22. Review of the skilled nursing documentation revealed beginning 05/01/22 through 06/11/22 skilled nursing services were decreased to twice weekly with no evidence of a physician order. Staff A confirmed in an interview on 07/20/22 at 4:47 PM that there was no physician order for skilled nursing services beginning 05/01/22 to decrease the frequency to twice weekly. Per Staff A the service was decreased based on insurance approval.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to ensure supervisory visits were conducted no less frequently than every fourteen days for patients who were receiving skilled care for one of three medical records reviewed (Patient #1). The agency census was 84. Findings include: Review of the policy titled, Home Health Aide Supervision, revised 2009, revealed all home health aide supervisory visits will be made at least every fourteen days to assure the appropriateness of the home health aide services and to maintain quality of care. Review of the medical record for Patient #1 for the certification period dated 04/13/22 through 06/11/22 revealed diagnoses to include type two diabetes, chronic obstructive pulmonary disease, and schizoaffective disorder. Per physician orders skilled nursing services were to be provided daily (Monday through Friday) until 04/30/22 and decreased to twice weekly effective 05/01/22. The home health aide was ordered to provide services fifteen hours weekly to assist with activities of daily living, meals, and housekeeping. Review of the supervisory visits revealed the last supervisory visit was conducted on 04/04/22. Staff B confirmed this finding in an interview on 07/20/22 at 6:13 PM.