Every finding on record at Premier Healthcare Services, Inc

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 06/09/2022 through 06/15/2022. On the first day of the survey, the Home Health Agency reported that their total active census was 180 patients, and their number of unduplicated admissions for skilled services, during the most recent 12-month period was 15 patients. The sample size consisted of 10 clinical records; including seven (7) required record reviews, and 3 (three) record reviews in place of Home Visits not conducted; 14 personnel records, plus the agency’s COVID-19 Staff Vaccination Matrix for Vaccination Compliance. In addition, the surveyor found the Home Health Agency to be in substantial 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 06/09/2022 through 06/15/2022. On the first day of the survey, the Home Health Agency reported that their total active census was 180 patients, and their number of unduplicated admissions for skilled services, during the most recent 12-month period was 15 patients. The sample size consisted of 244 OASIS Validation Reports, 14 personnel records, plus the agency’s COVID-19 Staff Vaccination Matrix for Vaccination Compliance, 10 clinical records; including seven (7) required record reviews, and 3 (three) record reviews in place of Home Visits not conducted. The surveyor cited Standard Level deficiencies based on observations, interviews with agency staff, telephone interviews with patients, patients' caregivers, review of clinical records, and the agency's policies. Glossary ASPEN-Automated Survey Processing Environment ADL's - Activities of Daily Living Bil. - Bilateral BP - Blood pressure CFR- Code of Federal Regulations CM- Clinical Modification cm - centimeters CMS - Centers for Medicare and Medicaid Services DC- District of Columbia D/C - discontinue; discharge DCMR - District of Columbia Municipal Regulations DME - Durable Medical Equipment Ext. - Extremity (ies) Form 485- Medicare Plan of Care HHA - Home Health Aide HHA- Home Health Agency ICD-10- CM Tenth Revision of the International Statistical Classification of Diseases- Clinical Modification i.e. - That is; in other words; for example NPI- National Provider Identifier mg - milligram(s) mg/dL - milligrams per deciliter ml - milliliter(s) NPH - Insulin/ Humulin (Novolin) [Intermediate acting] OASIS- Outcome and Assessment Information Set PCA - Personal Care Aide PERS- Personal Emergency Response unit PRN - As Needed PT - Physical Therapy (ist) REG- Regulation RN - Registered Nurse SN - Skilled Nurse (ing) SOC - Start of Care wk- week (s) www - World Wide Web % - 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 review of 10 clinical records, the agency's policy, and interview with agency staff, the registered nurse failed to ensure that the comprehensive assessment accurately reflected the patient’s status in one (1) of ten (10) clinical records (Patient # 8). Findings included … A review of the Home Health Agency's un-dated policy, reference number 10007, and 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 #8’s clinical record on 06/10/2022 at approximately 11:00 AM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 12/24/2018, and an annual Recertification Period of 11/01/2021 to 10/31/2022. The diagnoses listed on the Plan of Care included Acute on Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus, Spinal stenosis, Gout, Hypertension, Syncope and Collapse, Severe Stage 4, Chronic Kidney Disease, Long term (current) use of Insulin, Hypertensive Emergency, and Hyperlipidemia. The clinical record contained a ‘Patient Discharge Instructions’ report from an acute care facility with a discharge date of 05/12/2022. The ‘Patient and Medication Education’ section of the instructions revealed the patient’s initial complaints consisted of “…racing heart rate and your heart skipping beats…” In addition, the report showed Patient #8 was diagnosed and treated for Atrial Fibrillation. Additional review of the clinical record showed Employee #4, prepared a ‘Resumption of Care’ OASIS (Outcome and Assessment Information Set) comprehensive assessment dated 05/13/2022 that was incomplete, and did not accurately reflect Patient #8’s status. Further review of the assessment showed several blank spaces including and not limited to: i. The diagnoses listed on the assessment did not include Atrial Fibrillation; ii. Patient Living Situation; iii. Community Agencies/ Social Services Screening; iv. ‘Integumentary Status’ showed Employee # 4 recorded the note “Feet Assessed, no concerns noted…”; v. Fall assessment showed no boxes were marked; vi. Durable Medical Equipment (DME) showed no boxes were marked; and vii. Safety Measures showed no boxes were marked. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 11:55 AM.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on review of 10 clinical records, the agency's policy, and interview with agency staff, the registered nurse failed to ensure that the comprehensive assessment included the patient's current health, psychosocial, functional, and cognitive status in one (1) of ten (10) clinical records (Patient #8). Findings included … A review of the Home Health Agency's un-dated policy, reference number 10007, and 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 #8’s clinical record on 06/10/2022 at approximately 11:00 AM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 12/24/2018, and an annual Recertification Period of 11/01/2021 to 10/31/2022. The diagnoses listed on the Plan of Care included Acute on Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus, Spinal stenosis, Gout, Hypertension, Syncope and Collapse, Severe Stage 4, Chronic Kidney Disease, Long term (current) use of Insulin, Hypertensive Emergency, and Hyperlipidemia. The clinical record contained a ‘Patient Discharge Instructions’ report from an acute care facility with a discharge date of 05/12/2022. The ‘Patient and Medication Education’ section of the instructions revealed the patient’s initial complaints consisted of “…racing heart rate and your heart skipping beats…” In addition, the instructions show Patient #8 was diagnosed and treated for Atrial Fibrillation. Additional review of the clinical record showed Employee #4, prepared a ‘Resumption of Care’ OASIS (Outcome and Assessment Information Set) comprehensive assessment dated 05/13/2022. The comprehensive assessment was incomplete and did not include outcomes of that indicate assessment of the following items: i. Cognition; ii. Neuro/Behavioral; iii. Depression Screening, including PHQ-2 (Patient Health Questionnaire); iv. Fall Assessment; and v. DME Durable medical Equipment. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 11:55 AM.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interviews with agency staff, review of 10 clinical records and the agency's policy, the agency’s registered nurse failed update and revise comprehensive assessments in two (2) of ten (10) clinical records (Patients #5 and 10). Findings included... A review of the Home Health Agency's un-dated policy, reference number 10007, and titled Completion of the Comprehensive Assessment, shows that subsequent comprehensive assessments shall be conducted at various time points for a minimum at recertification, upon transfer to an inpatient facility, resumption of care, significant change in the patient's condition, and at discharge. A. The surveyor conducted a review of Patient #5’s clinical record on 06/10/2022 at approximately 2:30 PM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 06/13/2016, and an annual Recertification Period of 06/01/2021 to 07/31/2022. The diagnoses on the current Plan of Care included Type 2 Diabetes Mellitus, Asthma, Unsteadiness on Feet, Hypertension, Hyperlipidemia, Glaucoma, Peripheral Neuropathy, Gastro-Esophageal Reflux Disease, Gout, Morbid (Severe) Obesity, and Constipation. Additional review of the clinical record showed Employee#9 prepared an ‘RN Recertification’, non-OASIS (Outcome and Assessment Information Set) comprehensive assessment dated 04/16/2022. Further review of the clinical record lacked documented evidence of an updated and revised comprehensive assessment that corresponds with the current certification period of 06/01/2021 to 07/31/2022. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 11:20 AM. B. The surveyor conducted a review of Patient #10’s clinical record on 06/13/2022 at approximately 2:40 PM that showed a Plan of Care with a Start of Care date of 01/23/2018, and an annual Recertification Period of 09/01/2021 to 08/31/2022. The diagnoses on the current Plan of Care included Dependence on Renal Dialysis, Acquired Absence of Toe(s), Shortness of Breath, Transient Cerebral Ischemic Attack, Hypertension, and Hyperparathyroidism of Renal Origin. Additional review of the clinical record showed Employee#9 prepared a ‘Resumption of Care, OASIS (Outcome and Assessment Information Set) comprehensive assessment dated 03/09/2022. The clinical record lacked documented evidence of an updated and revised comprehensive assessment. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 11:20 AM.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of ten (10) records, the agency's policy, and interview with agency staff, the agency's staff failed revise of the plan of care to reflect all verbal order received during the certification period, so that all Home Health Agency staff are working from a current plan in one (1) of ten (10) clinical records (Patient #1). Findings included … A review of the Home Health Agency's policy, reference number 10004, titled “Plan of Care”, and dated 07/01/2021 shows that all orders from physicians involved in the plan of care will be integrated to assure the coordination of all services and interventions provided to the patient. The surveyor conducted a review of Patient #1’s clinical record on 06/10/2022 at approximately 1:30 PM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 07/24/2014, and an annual Recertification Period of 02/01/2022 - 01/31/2023. The diagnoses listed on the Plan of Care included Cerebro Vascular Accident, Stage IV Chronic Kidney Disease (CKD), and Chronic Obstructive Pulmonary Disease (COPD). Additional review of the clinical record showed Employee #9 entered verbal orders dated 03/04/2022, and 04/06/2022 in the electronic clinical record that were not recorded in the current plan of care. a. The verbal orders dated 03/04/2022 included the following medications: i. Sodium Bicarbonate 650 milligram oral tablet; 1 tablet 3 times daily by mouth gastrointestinal agents ii. Symbicort 160 microgram -4.5 microgram Inhalation Aerosol; 2 puffs daily Inhaled (INH) N bronchodilator combinations iii. Tylenol 500 milligram oral tablet; 2 tablets daily by mouth; and iv. Lasix 40 milligram oral tablet; 2 tabs daily by mouth b. The verbal orders dated 04/06/2022 included i. Lidocaine 5% Patch 1 patch daily, apply up to 12 hours daily, remove patch after 12 hours Transdermal; and ii. Entresto 24 milligram -26 milligram oral tablet; 1 tab in the morning and in the evening by mouth (PO) The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 12:40 PM.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interviews with agency staff, review of 10 clinical records and the agency's policy, the agency failed to ensure that verbal physician's orders were accepted only by personnel authorized to do so in accordance with applicable state laws and regulations in two (2) of ten (10) clinical records (Patients #3 and 6). Findings included … A review of the Home Health Agency's policy, reference number 8012, titled “Telephone/ Verbal Orders”, and dated 07/01/2021 shows that telephone/verbal physician orders are accepted by licensed staff, in accordance with the District of Columbia State scope of practice guidelines. A. The surveyor conducted a review of Patient #3’s clinical record on 06/13/2022 at approximately 11:30 AM that showed a Plan of Care with a Start of Care date of 03/16/2021, and an annual Recertification Period of 03/16/2021 to 02/28/2022. The diagnoses listed on the Plan of Care included Type 2 Diabetes Mellitus, Parkinson's disease, Hypertension, Hyperlipidemia, Major depressive Disorder, Abnormalities of Gait and Mobility, Functional Urinary Incontinence, and a history of falling. Additional review of the clinical record showed Employee#20, one of the agency’s Patient Care Coordinators, and unlicensed staff, documented a physician’s verbal order for a change in frequency for Personal Care Aide Services, dated 09/20/2021. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 12:20 PM. B. The surveyor conducted a review of Patient #6’s clinical record on 06/13/2022 at approximately 9:30 AM that showed a Plan of Care for Skilled Services with a Start of Care date of 11/17/2014, and a Recertification Period of 04/09/2022 to 06/07/2022. The diagnoses on the current Plan of Care included Acute Respiratory Failure with Hypoxia or Hypercapnia, Dysphagia, Tracheostomy, Gastrostomy, Anxiety disorder, and Recurrent Major Depressive Disorder. Additional review of the clinical record showed Employee#21, one of the agency’s Patient Care Coordinators, and unlicensed staff, documented a physician’s verbal order for a change in frequency for Personal Care Aide Services, dated 06/06/2022. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 11:40 AM.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on interviews with agency staff, review of 10 clinical records and the agency's policy, the agency’s registered nurse failed ensure that the Plan of Care was reviewed and revised in one (1) of ten (10) clinical records (Patient #8). Findings included … A review of the Home Health Agency's policy, reference number10004, titled “Plan of Care”, and dated 07/01/2021 shows that plans of care shall be reviewed by a Registered Nurse who shall update or modify the plan of care if necessary. The surveyor conducted a review of Patient #8’s clinical record on 06/10/2022 at approximately 11:00 AM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 12/24/2018, and an annual Recertification Period of 11/01/2021 to 10/31/2022. The diagnoses listed on the Plan of Care included Acute on Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus, Spinal stenosis, Gout, Hypertension, Syncope and Collapse, Severe Stage 4, Chronic Kidney Disease, Long term (current) use of Insulin, Hypertensive Emergency, and Hyperlipidemia. The clinical record contained a ‘Patient Discharge Instructions’ report from an acute care facility with a discharge date of 05/12/2022. The Patient and Medication Education section of the instructions revealed the patient’s initial complaints consisted of “…racing heart rate and your heart skipping beats…” In addition, the instructions show Patient #8 was diagnosed and treated for Atrial Fibrillation. Additional review of the clinical record showed Employee #4, prepared a ‘Resumption of Care’ OASIS (Outcome and Assessment Information Set) comprehensive assessment dated 05/13/2022. Further review of the clinical record lacked documented evidence of an updated and revised Plan of care to include the diagnoses of Atrial Fibrillation and associated precautions. The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 11:55 AM.

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 interviews with agency staff, review of 10 clinical records and the agency's policy, the agency's clinician failed to document a complete discharge summary that included the required items in one (1) of one (1) closed clinical record for a patient discharged from the agency (Patient #3). The findings included: A review of the Home Health Agency's policy, reference number10302, titled “Discharge Summary”, and dated 07/01/2021, shows that “Transfer/ Discharge Summary” information includes, but is not limited to a summary of the patient's physical, mental and emotional status at the time of transfer or discharge; the reasons for admission to home care and services received while admitted to home care, and so on. The surveyor conducted a review of Patient #3’s clinical record on 06/13/2022 at approximately 11:30 AM that showed a Plan of Care with a Start of Care date of 03/16/2021, and an annual Recertification Period of 03/16/2021 to 02/28/2022. The diagnoses listed on the Plan of Care included Type 2 Diabetes Mellitus, Parkinson's disease, Hypertension, Hyperlipidemia, Major depressive Disorder, Abnormalities of Gait and Mobility, Functional Urinary Incontinence, and a history of falling. Additional review of the clinical record showed the Home Health Agency provided Patient #3 with Personal Care Aide Services, eight hours for five days weekly. Further review of the clinical record showed Employee#6, a registered nurse, documented a "DC from [Agency Acronym] Discharge from Agency" summary report dated 04/30/2022. Patient #3's 'Discharge Summary' report was incomplete and did not contain the following items: i. Reason for admission to home health; ii. Medications the patient is on at the time of discharge; iii. Patient and family post-discharge instructions; iv. Patient’s discharge condition; and v. Patient outcomes in meeting the goals in the plan of care . The surveyor conducted a face-to-face interview with Employee #4, the Clinical Manager and Employee #7, Quality Assurance Coordinator who acknowledged and confirmed the findings on 06/15/2022 at approximately 12:20 PM.

The State Agency conducted an unannounced, federal complaint investigation #62124, on 02/28/2022 and 03/14/2022 to 03/16/2022. A standard level deficiency was cited for the agency’s failure to coordinate the patient’s services.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of 10 clinical records, the Agency's policies and procedures, and interviews with agency staff, patient, and the patient's caregiver, the Home Health Agency failed to ensure the coordination of care delivery to meet the patient's needs for one of ten patients (Patient #1). The Home Health Agency's policy, reference number 10021, titled “Coordination of Patient Services”, dated 01/31/2020 shows that when the patient is receiving care, treatment and/or services from other organizations/ providers, Premier Health Services Inc HHA ensures that the responsibilities of the HHA and other organizations/providers are collaborative and exclusive. Patient #1 is a Medicaid beneficiary who receives Home Personal Care Aide Services from the Home Health Agency. The surveyor reviewed Patient #1’s clinical record on 03/11/22 at approximately 3:35 PM that showed a combined comprehensive assessment for annual Recertification and Resumption of Care, dated 02/01/21. The assessment contained a physician’s order that directed the Skilled Nurse to care coordinate with the home health agency providing skilled care including physical, speech and language, and skilled nursing services. Additional review of the clinical record showed a revised Plan of Care for Personal Care Aide Services with a Start of Care date of 07/24/2014. Employee #2, a Registered Nurse, combined the plan of Care for annual Recertification and Resumption of Care with a Recertification Period of 02/01/2022 to 01/31/2023. The diagnoses listed on the Plan of Care included Cerebral Infarction, Type II Diabetes, Generalized Muscle Weakness, and Hypertension. Further review of the record showed a Face- to- Face physician’s order dated 11/30/2021 from the skilled nursing facility that prescribed physical, speech and language, and skilled nursing services. In addition, the record showed that the nurse involved Patient #1, and her caregiver in the revision of the Plan of Care to reflect the current information from the patient's updated comprehensive assessment, including the physician orders that prescribed the skilled services for Patient #1. Further review of the clinical record showed a note titled ‘Coordination Note’, dated 12/01/2021 that showed a care coordination meeting was conducted the staff of the skilled nursing facility explaining that the Patient #1 would be receiving physical, speech and language, and skilled nursing services from another agency. In addition, the communication reflected the initial assessment would occur during the week of 12/06/21 to12/10/21. The clinical record contained another ‘Communication Note’, dated 12/07/2021 that indicated Patient # 1 was transported to a local hospital via Emergency Services due to hyperglycemia and weakness on that day. Patient #1 was discharged to her home from the acute care. During a telephone interview with Patient #1’s son, who is her caregiver on 03/25/2022 approximately 3:00 PM, he stated that his mother’s condition was progressing well, and added that he was still working with the case manager so that his mother could receive physical therapy. The surveyor conducted a telephone interview with Employee #9 about the physician’s order included on the revised Plan of Care for skilled services. In response to the surveyor’s query, she stated that although the caregiver should have followed up, the agency staff should as well. The clinical record lacked documented evidence that the Home Health Agency’s staff communicated with the other agency regarding provision of skilled services for Patient #1’s care following her return home for Personal Care Aide services. The record did not include information regarding Patient #1 receiving therapy services provided by another agency, and the patient did not receive all services included in the Plan of Care. The surveyor conducted a telephone interview with Employee #9 on 03/29/2022 at approximately 4:00 PM who acknowledged and confirmed the findings.