Every finding on record at Mbi Health Services, LLC

The State Agency conducted an unannounced Federal Recertification Home Health Agency Survey from 05/17/2022 through 05/23/2022 for compliance with Emergency Preparedness requirements for Home Health Agencies. The Home Health Agency's total active census was 200 patients. Based on interviews with the Home Health Agency's staff, the surveyor found the Home Health Agency in compliance with the requirements for Emergency Preparedness Program. No deficiencies were cited.

The State Agency conducted an unannounced Federal Medicare/Medicaid Home Health Agency Recertification Survey from 05/17/22 through 05/23/22. The agency reported that the number of unduplicated admissions for skilled services during the most recent 12-month period was 5 patients. The sample consisted of twelve (12) clinical records, 16 personnel records, and three (3) patient/caregiver interviews. On the first day of the survey, the Home Health Agency reported the total active census was 200 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 BP- Blood Pressure CFR- Code of Federal Regulations CM- Clinical Modification CMS- Centers for Medicare and Medicaid Services COVID-19 - Coronavirus Disease 2019 DC- District of Columbia D/C- discontinue; discharge DCMR- District of Columbia Municipal Regulations DME- Durable Medical Equipment G-tube- Gastrostomy Tube HHA- Home Health Aide HHA- Home Health Agency mcg- microgram(s) mg- milligram(s) ml- milliliter(s) mm/Hg- milliliter(s) of Mercury OASIS- Outcome and Assessment Information Set items PCA- Personal Care Aide PT- Physical Therapy PRN- As Needed REG- Regulation RN- Registered Nurse ROC-Resumption of Care SN- Skilled Nurse (ing) SOC- Start of Care WHO-World Health Organization WK- week (s)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, and staff interviews, the Agency failed to ensure the clinician developed an individualized Plan of Care and included all required elements for three (3) of the nine (9) active clinical records reviewed (Patients #2, 3 and 4). Findings included: The Home Health Agency's policy titled, "Patient's Plan of Care- Personal Care Aide (PCA) services", dated 04/15/20 showed, that “the patient-specific plan of care will specify the care and services necessary to meet the patient's needs as identified in the comprehensive assessment. The patient-specific plan must include the pertinent diagnoses and the patient's mental, psychosocial, and cognitive status." 1. The surveyor reviewed Patient #2's clinical record on 05/18/22 at approximately 3:00 PM. The record contained a Plan of Care with a Start of Care date of 05/10/16 and a Certification Period from 12/01/21 to 11/30/22. Patient #1's diagnoses on the Plan of Care included Bilateral Hearing Loss, Type 2 Diabetes Mellitus, Legally Blindness, and Hypertension. A review of the clinical record showed a non-oasis recertification assessment dated 09/13/21 showed Patient #1 with a diagnosis of Malignant Neoplasm of the Brain. A review of Patient #1's Plan of Care did not include the diagnosis of Malignant Neoplasm of the Brain and the cognitive status. 2. The surveyor reviewed Patient #3's clinical record on 05/19/21, at approximately 11:15 AM. The record contained a Plan of Care with a Start of Care date of 01/18/19 and a Certification Period from 11/01/21 to 10/31/22. Patient #3's diagnoses on the Plan of Care included Stroke with Right-Sided Weakness and Hypertension. A review of Patient #3's Plan of Care did not include the cognitive status. 3. The surveyor reviewed Patient #4's clinical record on 05/19/21, at approximately 12:30 PM. The record contained a Plan of Care with a Start of Care date of 07/21/21 and an Initial Certification Period from 07/21/21 to 06/30/22. Patient #4's diagnoses on the Plan of Care included Chronic Pulmonary Embolism, Heart Disease with Heart Failure, Arthritis, and Hyperaldosteronism. A clinical record review showed a non-oasis recertification assessment dated 07/31/21 showed Patient #4 with diagnoses of Asthma, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. A review of Patient #4's Plan of Care did not include the following diagnoses Asthma, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and cognitive status. The Plan of Care lacked documented evidence of completion to include all pertinent diagnoses and the cognitive status of all patients identified. The surveyor conducted a face-to-face interview with Employees #2 (Administrator) and #3 (Clinical Director) on 05/23/21 at approximately 3:30 PM. Both 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, policy review, and staff interviews, the Home Health Agency failed to ensure the clinician completed discharge summaries to include care provided for three (3) of three (3) discharged patients (Patients #10, 11, and 12). Findings included… The Home Health Agency’s policy titled, “Client Discharge Process,” undated, showed that the Discharge summary will include the following: the initial reason for referral to the home health agency, a description of all services provided, and a description of the client’s clinical, mental, psychosocial, cognitive, and functional status at end of care. 1. The surveyor reviewed Patient #10’s closed clinical record on 05/20/22 at approximately 10:45 AM. Patient #10’s Plan of Care showed a Start of Care date of 08/30/21 and an Initial Certification Period from 08/30/21 to 07/31/22. The diagnoses included Nonrheumatic Mitral Valve Insufficiency, Major Depressive Disorder, Type 2 Diabetes Mellitus, Dorsalgia, Heart Disease, Anemia, Acute Kidney failure, and Acute Chronic Systolic (Congestive) Heart Failure. Physician’s orders on the Plan of Care directed the skilled nurse to visit one (1) to three (3) times a month to perform complete assessments and supervision of the Personal Care Aide (PCA). The Plan of Care included orders for a PCA eight (8) hours a day for seven (7) days a week, for 12 months to assist with activities of daily living, meal preparation, running errands, and accompanying the client to appointments. A physician’s order dated 03/28/22 at 9:30 AM showed the Personal Care Aide (PCA) reported on 03/28/22 that Patient #10 expired on 03/25/22 at home in the presence of the daughter. The physician’s order also directed PCA services be discontinued effective 03/25/22. A review of the closed clinical record lacked evidence of a discharge summary including the admission date, the reason for admission to home health, types of services provided, and frequency. 2. The surveyor reviewed Patient #11’s closed clinical record on 05/20/22 at approximately 11:30 AM. Patient #11’s Plan of Care showed a Start of Care date of 03/25/21 and an Initial Certification Period from 03/25/21 to 02/28/22. The diagnoses included Generalized Muscle Weakness, Altered Mental Status, Malignant Neoplasm of the Colon, Chronic Obstructive Pulmonary Disease, and Hypertension. Physician’s orders on the Plan of Care directed the skilled nurse to visit one (1) to three (3) times a month to perform complete assessments and supervision of the Personal Care Aide (PCA). The Plan of Care included orders for a PCA eight (8) hours a day for seven (7) days a week, for 12 months to assist with activities of daily living, meal preparation, running errands, and accompanying the client to appointments. A physician’s order dated 02/28/22 at noon showed Patient #11’s services were placed on Hold and then later moved to Adelphi Nursing Home in Hyattsville, MD. Patient #11 requested discharge. A 30-day notice was mailed on 03/22/22 and Patient #11 was discharged on 04/22/22. A review of the closed clinical record lacked evidence of a discharge summary including the admission date, the reason for admission to home health, types of services provided, and frequency, and a narrative summary of the care/services provided with progression towards an established goal, and the patients overall status. 3. The surveyor reviewed Patient’s #12 closed clinical record on 05/20/22 at 12:15 PM. Patient #12’s Plan of Care showed a Start of Care date of 07/21/2016 and a Recertification Period from 05/01/21 to 04/30/22. The diagnoses included Type 2 Diabetes Mellitus, Hypertension, Abnormalities of Gait and Mobility, Low Vision Right Eye, Blindness Left Eye, and Cerebrovascular Disease. Physician’s orders on the Plan of Care directed the skilled nurse to visit one (1) to three (3) times a month to perform complete assessments and supervision of the Personal Care Aide (PCA). The Plan of Care included orders for a PCA eight (8) hours a day for seven (7) days a week, for 12 months to assist with activities of daily living, meal preparation, running errands, and accompanying the client to appointments. A physician’s order dated 03/30/22 at 12:00 noon showed Patient #12’s services were placed on Hold and requested to be discharged. A 30-day notice was mailed on 03/22/22 and Patient #12 was discharged on 04/22/22. A review of the closed clinical record lacked evidence of a discharge summary including the admission date, the reason for admission to home health, types of services provided, and frequency, and a narrative summary of the care/services provided with progression towards an established goal, and the patients overall status. The surveyor conducted a face-to-face interview with Employees #2 (Administrator) and #3 (Clinical Director) on 05/23/21 at approximately 3:30 PM. Both employees acknowledged the findings.