Every finding on record at Linac Services Inc

The State Agency conducted an unannounced Federal Medicare/Medicaid recertification Survey from 01/09/23 through 01/17/23 for compliance with Emergency Preparedness requirements for Home Health Agencies. The Home Health Agency's total active census was 130 patients. Based on a review of the Emergency Preparedness Program and an interview with the Home Health Agency's staff, the surveyor found the Home Health Agency in compliance with the requirements for the Emergency Preparedness Program. No deficiencies were cited.

The State Agency conducted an unannounced Federal Medicare/Medicaid Home Health Agency Recertification Survey from 01/09/23 through 01/17/23. The Agency reported that the number of unduplicated admissions for skilled services during the most recent 12-month period was nine (9) patients. The sample consisted of ten (10) clinical records, 16 personnel records, and three (3) patient interviews. On the first day of the survey, the Home Health Agency reported the total active census was 130 patients. Standard-level deficiencies were cited based on observations, interviews with agency staff, patients' caregivers, review of clinical records, and the agency's policies. Glossary ADLs- Activities of Daily Living BID- Two times a day CFR- Code of Federal Regulations CM- Clinical Modification CMS - Centers for Medicare and Medicaid Services DCMR- District of Columbia Municipal Regulations DME - Durable Medical Equipment ER - Emergency Room G-Tube - Gastrostomy Tube G-J Tube - Gastro-Jejunal Tube HHA- Home Health Aide HHA- Home Health Agency IADLs -Instrumental Activities of Daily Living LPN - Licensed Practical Nurse mg - milligram(s) ml - milliliter(s) OASIS- Outcome and Assessment Information Set Items PCA- Personal Care Aide PRN - As Needed REG- Regulation RN - Registered Nurse SN - Skilled Nurse (ing) SOC - Start of Care VA Shunt - Ventriculoarterial Shunt WK- week (s) WNL - within normal limits % - Percentage

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review, policy review, and staff interviews, the Home Health Agency staff failed to complete comprehensive assessments to accurately reflect the patient's current health status in two (2) of seven (7) active clinical records receiving skilled services, (Patients #3 and 4). Findings included… The Home Health Agency's undated policy (#10007) titled, "Completion of the Comprehensive Assessment," shows that the comprehensive assessment will reflect the patient’s current health status and include information to establish and monitor a plan of care. The surveyor conducted a review of Patient#3's clinical record on 01/11/23 at approximately 11:00 AM that showed a Start of Care Comprehensive Assessment, and the Plan of Care for the Start of Care dated 07/20/19 included the following diagnoses: Trisomy 18, Scoliosis, Protein Calorie Malnutrition, Global Developmental Delay, Dysphagia, Chronic Constipation, and Bradycardia. The clinical record also included discharge instructions from an acute care facility dated 01/10/20 that showed a history of procedures performed to include Femur Closed Reduction with Percutaneous pinning (right leg)- 10/16/19; Hardware removal Smith & Nephew (left leg)-09/10/19; Patella Open Reduction Internal Fixation (left leg) – 09/10/19. Additional review of the clinical record showed ‘Registered Nurse (RN) Assessment’(s) [nursing Visit Notes] dated 12/14/22, and 12/24/22 included the following documented diagnoses: Disorders of Psychological Development, Gastrostomy Status, Bradycardia, and Aspiration Pneumonitis, and did not include findings from the discharge instructions. An additional review of the clinical record lacked documented evidence that the Home Health Agency staff provided a complete comprehensive assessment that accurately reflected Patient #3's current health status. The surveyor conducted a face-to-face interview with Employees #1 (Administrator), and 2 (Clinical Manager), on 01/17/23 at approximately 3:00 PM. The employees acknowledged the findings.

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, policy review, and staff and caregiver interviews, the Home Health Agency failed to ensure the clinician developed an individualized Plan of Care and included all required elements including all pertinent diagnoses, medications, and other required elements relative to the patient for two (2) of the seven (7) active clinical records reviewed (Patient's #3, and 4 ). Findings included… A review of the Home Health Agency's Policy (#10004) titled, "Plan of Care", revised on 07/01/18, showed the Plan of Care includes the physical assessment, including all pertinent diagnoses, all medications, and treatments. The Plan of Care must be established and authorized in writing by the physician based on an evaluation of the patient’s immediate and long-term needs. A. A review of Patient #3's clinical record on 01/11/23, at approximately 11:00 AM, showed a Plan of Care with a Start of Care date of 07/20/19 and a Recertification Period from 12/31/22 to 02/28/23. Patient #3's diagnoses on the Plan of Care included Trisomy 18, Gastrostomy/Gastrostomy Tube (G-Tube) feeding, Scoliosis, Global Developmental Delay, and Protein-Calorie Malnutrition. A review of the Plan of Care item titled ‘Orders for Discipline and Treatment’ directed the Registered Nurse (RN) to conduct two (2) home visits monthly for general assessment, evaluation, and supervision of care. In addition, the physician’s orders on the Plan of Care directed the Licensed Practical Nurse (LPN) to provide patient care for eight (8) hours a day, seven (7) days a week to administer medication, feedings, and treatments. The LPN will perform a general physical assessment and provide continuous monitoring of patient care every shift. The Home Health Aide/Personal Care Assistant (HHA/PCA) provide services eight (8) hours a day times seven (7) days a week to assist patient with Activities of Daily Living (ADLs) and maintain a clean and safe environment. Further review of the clinical record, Registered Nurse (RN) reassessment dated 12/14/22 and 12/24/22 showed the following documented diagnoses: Trisomy 18, Protein-Calorie Malnutrition, Disorders of Psychological Development, Gastrostomy Status, Constipation, Bradycardia, and Aspiration Pneumonitis. In addition, the 60-day progress note dated 12/14/22 showed the current diagnoses to include Trisomy, Scoliosis, Protein Calorie Malnutrition, Global Developmental Delay, Dysphagia, Chronic Constipation, and Bradycardia. The Plan of Care did not include the following diagnoses, Disorders of Psychological Development, Chronic Constipation, Dysphagia, Bradycardia, Aspiration Pneumonitis, A review of discharge instructions from a local hospital dated 01/10/20 showed a history of procedures performed to include Femur Closed Reduction with Percutaneous pinning (right leg)- 10/16/19, Hardware removal Smith & Nephew (left leg)-09/10/19, Patella Open Reduction Internal Fixation (left leg) – 09/10/19, that was not included in the Plan of Care. A review of the Plan of Care updated item titled, ‘Nutrition ‘showed Diet as Formula: Bright beginning Soy, administer 8 ounces five times daily. A review of the RN assessment item, ‘Nutrition’ dated 12/14/22 and 12/24/22 showed Nutritional Supplement Pediasure 225 ml bolus feeds twice a day (BID) at 112 milliliter/hour (ml/hr) plus overnight feeds 8 hours at 75ml/hr. The Plan of Care item, titled, ‘Medications’ listed four (4) medications. A review of the Mediation Administration Record (MAR) dated December 2022, showed a listing of seven (7) medications. The Plan of Care medication listing did not include the following medications: Multivitamins, Acetaminophen 160 milligrams/5 milliliters, and Oxycodone 5 milligram/5 milliliter oral solution. The Plan of Care did not include the cognitive status. B. A review of Patient #4’s clinical record on 01/11/23 at approximately 1:30 PM showed a Plan of Care with a Start of Care date of 05/03/22 and a recertification period from 12/29/22 to 02/26/23. Patient #4’s diagnoses included Spastic Quadriplegia Cerebral Palsy, Tracheostomy/Ventilator Dependent, Gastro-Jejunal Tube (G-J Tube) Feeding, Chronic Respiratory Failure, Epilepsy, and Ventriculoarterial (VA) shunt. A review of the Plan of Care item titled ‘Orders for Discipline and Treatment’ directed the Registered Nurse (RN) to conduct two (2) home visits monthly for general assessment, evaluation, and supervision of care. In addition, the physician’s orders on the Plan of Care directed the Licensed Practical Nurse (LPN) to provide patient care for twenty hours a day, seven (7) days a week to administer medication, feedings, and treatments per physician orders. The LPN performs a general physical assessment and provides continuous monitoring of patient care every shift. Further review of the clinical record, Registered Nurse (RN) reassessment dated 11/01/22 and 12/02/22 showed the following documented diagnoses Hydrocephalus, Global Developmental Delays, and Gastrotomy Status. The Plan of care did not include the following diagnoses, Hydrocephalus, Global Developmental Delays, and Gastrojejunostomy Status. A review of the Plan of Care item, ‘Medications’ listed seventeen (17) medications. A review of the Medication Profile dated 12/2/22 showed a listing of eighteen (18) medications. The Plan of Care medication listing did not include the following medications: Mupirocin 2% Topical Ointment, Potassium Phosphate, Magnesium Hydroxide, and Penicillin G Potassium. The Plan of Care did not include the cognitive status. The Plan of Care lacked documented evidence of completion of all required elements, including all pertinent diagnoses, medications, treatments, and cognitive status of the patients identified. The surveyor conducted a face-to-face interview with Employees #1 (Administrator), and 2 (Clinical Manager), on 01/17/23 at approximately 3:00 PM. The employees acknowledged the findings.

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 clinical record review, the Home Health Agency's policy review, and staff interviews, the Home Health Agency failed to submit completed discharge summaries within five (5) business days of discharge to the primary care physicians for three (3) of three (3) closed clinical record reviews. (Patients # 8, 9, and 10). Based on clinical record review, the Home Health Agency's policy review, and staff interviews, the Home Health Agency failed to submit completed discharge summaries within five (5) business days of discharge to the primary care physicians for three (3) of three (3) closed clinical record reviews. (Patients # 8, 9, and 10). Findings included… Record review of the Home Health Agency's undated policy titled, "Discharge/Transfer/Referral of Patients," showed "a copy of the discharge summary will be sent to the primary care physician and documentation be placed in the patient record evidencing that the physician was notified of the discharge." A. The surveyor reviewed Patient #8's closed clinical record on 01/13/23 at approximately 10:30 AM. The clinical record included a Plan of Care with a Start of Care date of 07/29/22 and an Initial Certification Period from 07/29/22 to 07/28/23. The diagnoses included Autistic Disorder, Attention Deficit Hyperactivity Disorder, Developmental Disorder of Speech and Lung, and Morbid Obesity. A review of the closed clinical record showed a completed Discharge Summary dated 12/10/22. The closed clinical record review lacked documented evidence that the Home Health Agency staff submitted Patient #8's discharge summary to the primary care physician within five (5) business days of discharge. B. The surveyor reviewed Patient #9's closed clinical record on 01/13/23 at approximately 11:30 AM. The closed clinical record included a Plan of Care with a Start of Care date of 02/27/17 and a Recertification Period from 02/01/22 to 01/31/23. The Diagnoses included Polycystic Kidney, Acute Kidney Failure, Sepsis, and Disorder of Urinary System. A review of the closed clinical record showed a completed Discharge Summary dated 10/07/22. The closed clinical record review lacked documented evidence that the Home Health Agency staff submitted Patient #9's discharge summary to the primary care physician within five (5) business days of discharge. C. The surveyor reviewed Patient #10's closed clinical record on 01/13/23 at approximately 12:15 PM. The closed clinical record included a Plan of Care with a Start of Care date of 01/04/16 and a Recertification Period from 09/27/22 to 09/26/23. The Diagnoses included Down Syndrome and lack of expected normal Physiological Development. A review of the closed clinical record showed a completed Discharge Summary dated 10/28/22. The closed clinical record review lacked documented evidence that the Home Health Agency staff submitted Patient #10's discharge summary to the primary care physician within five (5) business days of discharge. The surveyor conducted a face-to-face interview with employees #1 (Administrator) and 2 (Clinical Manager) on 01/13/23 at approximately 3:30 PM, related to notifying the physician of a discharge. Employee #1 stated we fax the discharge summary to the physician, but we do not routinely keep the fax confirmation. The Home Health Agency staff failed to submit a completed discharge summary to the primary care physician within a specified time for Patients #8, 9, and 10. The surveyor conducted a face-to-face interview with Employees #1 (Administrator) and 2 (Clinical Manager) on 01/17/23 at approximately 3:00 PM. The employees acknowledged the findings.