Every finding on record at Optima Professional Services Inc

An Emergency Preparedness survey was initiated with the Administrator/Director of Nurses on 10/16/2024 at 9:30 AM. Census: L&C- 2 LHH- 0 PAS- 0 The agency was found to be in substantial compliance with the Medicare Conditions of Participation for Emergency Preparedness, no deficiencies were cited.

A recertification survey was initiated with the Administrator/Director of Nurses on 10/16/2024 at 9:30 AM. Census: L&C- 2 LHH- 0 PAS- 0 Acronyms: POC- Plan of Care SOC- Start of Care SN- Skilled nurse DON- Director of Nurses

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 record reviews, observation and interviews, the agency failed to ensure the patient plan of care was complete and included all required elements for 1 (Patient #1) of 1 patient whose record included foley catheter change (a foley catheter is a flexible tube that drains urine from the bladder into a collection bag). This failure potentially placed the patient at risk of infection and complications with performance of the foley catheter when the SN did not have instructions for the frequency of the foley catheter to be changed every other week. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 07/08/2024 to 09/05/2024 with a SOC 05/05/2021. The POC included the following diagnoses: “Multiple sclerosis; Encounter for … Urinary device; … Disfunction of Bladder and Retention of urine… “ Physician orders included SN frequency twice a week for one week, once a week for eight weeks and two as needed visits for foley malfunction. Review of the record in the EHR system and the hard copy chart did not reveal any additional physician order for the frequency of the foley catheter change. The POC did not include the frequency for the SN to change the foley catheter every other week. During a home visit interview with Patient #1 and the family member caregiver, FM D on 10/18/2024 at 8:00 AM, the surveyor asked about the care and services received by the agency and staff nurse. Patient #1 was non-verbal and FM D answered for Patient #1. Identifier D stated the RN (Administrator/DON) visited every week and checked the Patient’s vital signs, cleaned and dressed the g-button (a small tube inserted into the stomach to provide nutrients, fluid and medications) and checked the Patient’s skin. The RN (Administrator/DON) also changed the foley catheter every other week. In an interview with the Administrator/DON on 10/18/2024 at 10:30 AM, the surveyor reviewed the findings and the POC. The surveyor asked if there was an order from the physician for the foley catheter to be changed every two weeks. The Administrator/DON reviewed Patient #1’s record and stated, “it might be missed. This is a big oversight. This is mind boggling. That’s what I’ve been doing, what happened? I’ve been doing it every two weeks a long time, I don’t know what to tell you.” Agency policy, revised date 01/29/2020, quoted in part, “CARE PLANNING PROCESS, … The 485, which includes the following plan of care elements, is developed in consultation with staff, client, physician and other providers involved in the client’s care and will serve as the initial plan of care: … types of services, supplies and equipment required; frequency and duration of visits to be made; … specific procedures/treatments to be performed; …”

A Recertification Survey entrance conference was conducted with the Administrator/DON on 09/23/2021 at 11:50 AM. Census: L and C- 5 LHHS- 0 PAS- 0 An exit conference was conducted with the Administrator/DON on 10/07/2021 at 3:50 PM. The preliminary findings were discussed. The agency was afforded an opportunity to provide additional information. Written instructions were provided to the Administrator/DON for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviation List: DON- Director of Nurses

A Recertification Survey entrance conference was conducted with the Administrator/DON on 09/23/2021 at 11:50 AM. Census: L and C- 5 LHHS- 0 PAS- 0 An exit conference was conducted with the Administrator/DON on 10/07/2021 at 3:50 PM. The preliminary findings were discussed. The agency was afforded an opportunity to provide additional information. Written instructions were provided to the Administrator/DON for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviation List: SOC- Start of Care MS- Multiple Sclerosis PRN- As Needed DM-2- Diabetes Mellitus-2 HTN- Hypertension CKD- Chronic Kidney Disease SN- Skilled Nurse DON- Director of Nurses POC- Plan of Correction meds- medications

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 3 (Patients #1, 4 and 5) of 3 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. FINDINGS INCLUDE: According to the Code of Federal Regulations 484.60(e)(1), the agency is required to provide each client with a “Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA.” Patient #1: Record review of the clinical record included a POC with a SOC date 05/25/2021 and a certification period 07/24/2021-09/21/2021. The POC included the following diagnoses: MS; Neuromuscular dysfunction of bladder; Urinary device; Aphasia and Gastrostomy. Physician orders included SN visits once a week and 2 PRN visits for exacerbation of disease process, Foley malfunction. Review of the record revealed no evidence that a visit schedule had been provided to Patient #1. During a home visit with Patient #1 on 09/28/2021 at approximately 7:30 AM, the patient's home folder was reviewed. The patient was non-verbal and the surveyor asked Patient #1's caregiver if any paperwork from the home folder had been removed or placed elsewhere? The caregiver stated, "I'm not sure, it should all be there, there's nothing in another folder or on the fridge." The surveyor asked if a written visit schedule to show when the SN would be visiting was provided to the patient or caregiver? The caregiver said, "there's no written schedule, but the nurse usually comes on Tuesdays and sometimes another day to change the catheter if needed." The home folder did not include a visit schedule for the patient. Patient #4: Record review of the clinical record included a POC with a SOC date of 06/28/2021 and a certification period 06/28/2021-08/26/2021. The POC included the following diagnoses: DM-2; HTN; Long Term (Current) use of Insulin and Low back pain. The SN visit frequency was ordered twice a week for two weeks and once a week for seven weeks. Review of the record revealed no evidence that a visit schedule had been provided to Patient #4. During a home visit with Patient #4 on 09/28/2021 at approximately 10:30 AM, the patient's home folder was reviewed. The surveyor asked Patient #4 if any paperwork from the home folder had been removed or placed elsewhere? Patient #4 stated, "everything is in there." The surveyor asked if a written visit schedule to show when the SN would be visiting was provided to the patient? Patient #4 stated, "no, but she (SN) comes on Tuesdays and sometimes Fridays." The home folder did not include a visit schedule for the patient. Patient #5: Record review of the clinical record included a POC with a SOC date of 08/24/2021 and a certification period 08/24/2021-10/22/2021. The POC included the following diagnoses: Hypertensive heart and CKD with heart failure; DM-2 and Cutaneous abscess of buttock. The SN visit frequency was ordered twice a week for two weeks and once a week for seven weeks. Review of the record revealed no evidence that a visit schedule had been provided to Patient #5. During a home visit with Patient #5 on 09/28/2021 at approximately 9:30 AM, the patient's home folder was reviewed. The surveyor asked Patient #5 if any paperwork from the home folder had been removed or placed elsewhere? Patient #5 stated, "no." The surveyor asked if a written visit schedule to show when the SN would be visiting was provided to the patient? Patient #5 stated, "not that I know." The home folder did not include a visit schedule for the patient. In an interview with the Administrator/DON on 10/07/2021 at approximately 2:30 PM, the surveyor presented the above findings of no visit schedules provided to the patients. The Administrator stated, "I don't know why those things were missing."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide patients with written medication schedule/instructions in 3 (Patient's #1, 4 and 5) of 3 patients home folders reviewed during a home visit, the agency failed to provide a medication schedule with instructions written in plain language, without medical abbreviations, to the patients. This failure placed the agency's patients at risk of adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicated drug therapy and noncompliance with drug therapy. FINDINGS INCLUDE: Patient #1: Record review of the clinical record included a POC with a SOC date 05/25/2021 and a certification period 07/24/2021-09/21/2021. The POC included the following diagnoses: MS; Neuromuscular dysfunction of bladder; Urinary device; Aphasia and Gastrostomy. The POC listed 8 different medications. Review of the record revealed no evidence a medication schedule/instructions written in plain language had been provided to Patient #1 or the caregiver. During a home visit with Patient #1 on 09/28/2021 at approximately 7:30 AM, the patient's home folder was reviewed. The patient was non-verbal and the surveyor asked Patient #1's caregiver if any paperwork from the home folder had been removed or placed elsewhere? The caregiver stated, "I'm not sure, it should all be there, there's nothing in another folder or on the fridge." The surveyor and Patient #1's caregiver discussed the current medications. The caregiver stated, "I crush all the meds, I know everything she takes." The surveyor found no evidence of a medication list for Patient #1, written in plain language in the patient's home folder. Patient #4: Record review of the clinical record included a POC with a SOC date of 06/28/2021 and a certification period 06/28/2021-08/26/2021. The POC included the following diagnoses: DM-2; HTN; Long Term (Current) use of Insulin and Low back pain. The POC listed 12 different medications. Review of the record revealed no evidence a medication schedule/instructions written in plain language had been provided to Patient #4. During a home visit with Patient #4 on 09/28/2021 at approximately 10:30 AM, the patient's home folder was reviewed. The surveyor asked Patient #4 if any paperwork from the home folder had been removed or placed elsewhere? Patient #4 stated, "everything is in there." The surveyor and Patient #4 discussed the current medications. The surveyor asked if a written medication list had been provided to the patient? Patient #4 stated, "no, I don't have a list, I know my meds." The surveyor found no evidence of a medication list for Patient #4, written in plain language in the patient's home folder. Patient #5: Record review of the clinical record included a POC with a SOC date of 08/24/2021 and a certification period 08/24/2021-10/22/2021. The POC included the following diagnoses: Hypertensive heart and CKD with heart failure; DM-2 and Cutaneous abscess of buttock. The POC listed 13 different medications. Review of the record revealed no evidence a medication schedule/instructions written in plain language had been provided to Patient #5. During a home visit with Patient #5 on 09/28/2021 at approximately 9:30 AM, the patient's home folder was reviewed. The surveyor asked Patient #5 if any paperwork from the home folder had been removed or placed elsewhere? Patient #5 stated, "no." The surveyor and Patient #5 discussed the current medications. The surveyor asked if a written medication list had been provided to the patient? Patient #5 stated, "I feel the shape of the pills, I know what meds I take and my daughter sets up my box." The surveyor found no evidence of a medication list for Patient #5. In an interview with the Administrator/DON on 10/07/2021 at approximately 2:30 PM, the surveyor presented the above findings of no medication schedule/instructions or list were provided to the patients. The Administrator stated, "I don't know why those things were missing."