Every finding on record at Maxicare Home Health Services

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/15/23. Standard level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/13/23 at 10:00 AM. The plan and policy lacked a date of when it was last updated or revised. 2. During an interview with the Administrator, Director of Nursing and Nursing Supervisor on 12/13/23 at 10:30 AM, the Administrator stated that the last time the Emergency Preparedness plan and policy were updated was in 2019. During the same interview, the above finding was confirmed.

Recertification survey completed. Maxicare Home Health Services, Inc dba Northcare Home Health Services was in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies as of survey date of 12/15/23.

Full survey completed. Standard level deficiencies cited. A Focused Infection Control Survey was conducted on 1/7/21. The Agency was in compliance with the Requirements for Infection Control for COVID-19. Abbreviations: COVID-19 = Coronavirus Disease 2019 POC = Plan of care Pt./Pts. = Patient/patients RN = Registered Nurse SN = Skilled Nurse SOC = Start of care AM = Morning PM = Afternoon NOS = Not Otherwise Specified cm = Centimeters

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(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: . A. Based on clinical record review, Agency Policy review and staff interviews, the Agency failed to ensure that changes in skin condition were reported to the physician. This affected 2 of 7 (Pts. #9 and #14) patients reviewed with alteration in skin integrity. Findings include: 1. Pt. #9. SOC 12/11/20 Diagnosis: Fracture unspecified part of neck of lower femur. The clinical record was reviewed on 1/6/21 at 10:45 AM. The initial comprehensive assessment on 12/11/20 included documentation of the following wounds: a surgical incision on left hip and 2 lesions, 1 on the left anterior leg and the other on the left leg. The SN visit note dated 12/28/20 included documentation of the following: pressure ulcer on right lateral ankle with an onset date on 12/24/20. The clinical record lacked documentation of physician notification for development of a new pressure ulcer. 2. Pt. #14. SOC 5/11/20. Diagnosis: COVID-19. The clinical record was reviewed on 1/6/21 at 2:00 PM. The SN visit note dated 5/14/20 and 5/19/20 included documentation that skin was intact. The SN visit note dated 5/21/20 included the following: " ...has light rash of bilateral cheeks with multiple red raised areas measuring approximately 0.4 x 0.4 cm ...described as itchy from time to time ...to report to SN if facial rash becoming worse ..." The clinical record lacked documentation of physician notification for a change in skin condition. 3. The Agency policy titled Nursing Services dated 7/2011 was reviewed on 1/7/21 at 10:00 AM and includes documentation, "19. The SN informs physician and Nurse Supervisor within four (4) hours of changes in patient's condition in accordance with physician's orders and documents communication with physicians appropriately." 4. During an interview was conducted with the Administrator, Director of Nursing and Quality Assurance RN on 1/6/21 between 4:15 PM to 5:00 PM, the above findings were confirmed. The Director of Nursing stated that the nurse should report changes of condition to the physician.

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 orders; This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy review and staff interview, it was determined the Agency failed to ensure the documentation in the clinical records and POC were complete and accurate. This was found in 2 of 12 (Pts. #8 and #9) active clinical record reviewed. Findings include: 1. Pt. #8. SOC 8/5/20. Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 1/6/21 at 9:30 AM. The POC for the period 12/3/20 to 1/31/21 contained documentation that Pt. #8 has a Pulmonary Artery Catheter but lacked interventions for its care. 2. Pt. #9. SOC 12/11/20. Diagnosis: Fracture unspecified part of neck of lower femur. The clinical record was reviewed on 1/6/21 at 10:45 AM. The initial comprehensive assessment on 12/11/20 included documentation of the following wounds: a surgical incision on left hip and 2 lesions, 1 on the left anterior leg and the other on the left leg. Pt. #9's SN notes dated 12/11/20 and 12/24/20 included documentation under Integumentary system: skin "Intact." The SN inaccurately documented Pt. #9's skin assessment on the SN note. Pt. #9's wound notes included the following documentation: On 12/17/20: Type of wound - #1 Wound NOS, open ... wound re-opened left leg; On 12/21/20: Type of wound - #1 Venous stasis wound, status - open ...wound re-opened on left leg and Type of wound - #2 Pressure ulcer, status - closed, wound measures 1.5 x 0.8 cm; On 12/28/20: Type of wound- #1 Traumatic wound, left leg; #2 Pressure ulcer, status - closed, wound measures 1.5 x 0.8 cm. The SN inaccurately documented the types and status of wounds. During an interview with the Quality Assurance RN and Director of Nursing on 1/6/21 between 4:15 to 5:00 PM, the Director of Nursing stated that Wound #1 should be labeled with the same type of wound consistently and, the wound status on the pressure ulcers were incorrectly documented and should have been labeled as "open." 3. The Agency policy titled "Nursing Services" which was dated 7/2011, includes documentation, "31. The SN completes, clear, concise and accurate clinical notes documenting skilled services and other required documentation appropriately and submit them to the agency on a timely basis..." The Agency undated policy titled "Documenting the Visit" includes documentation, "9. ...Complete documentation of the comprehensive care plan are important... 11. Care plan should address all care delivered to the patient on the basis of all identified problems..." 4. During an interview with the Administrator, the Director of Nursing and the Quality Assurance RN on 1/6/21 between 4:15 to 5:00 PM, the above findings were confirmed. They stated that the documentation should be accurate and complete.