Every finding on record at Premium Select Home Care, Inc

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey, in conjunction with a complaint investigation; #70823, from 05/09/2022 to 05/25/2022. 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 50 patients. The sample size consisted of 26 OASIS Validation Reports, 32 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. 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, in conjunction with a complaint investigation; #70823, from 05/09/2022 to 05/25/2022 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 50 patients. The sample size consisted of 26 OASIS Validation Reports, 32 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 mg - milligram(s) mg/dL - milligrams per deciliter ml - milliliter(s) NPH - Insulin/ Humulin (Novolin) [Intermediate acting] 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

At discharge CFR(s): 484.55(d)(3) At discharge. 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 assessment at discharge in one (1) of one (1) closed clinical record for a patient discharged from the agency (Patient #6). Findings included: A review of the Home Health Agency's policy, reference number 223, titled “Patient Discharge ‘shows that all discharges will have a discharge summary. The discharge summary will include the patient’s physician, summary of the patient’s stay including treatments, symptoms, and pain management. The surveyor conducted a review of Patient #6’s clinical record on 05/12/2022 at approximately 3:20 PM that showed a Plan of Care for Skilled Services with a Start of Care date of 01/15/2022, and a Recertification Period of 03/16/2022 to 05/14/2022. The diagnoses listed on the Plan of Care included Cerebrovascular Disease, Osteoarthritis, Chronic Ischemic Heart Disease, Disorder of Done Density and Structure, Peripheral Vascular Disease, Leg Pain, Atrial Fibrillation, and Essential Hypertension. Additional review of the clinical record showed the Home Health Agency provided Patient #6 with skilled services including physical therapy. Further review of the clinical record showed Employee#13, a physical therapist, documented a ‘Discharge from Agency Comprehensive Assessment-Physical Therapy’ report dated 05/11/2022. Patient #6's 'Discharge Summary' report was incomplete and did not contain the following items: i. Reason for admission to home health; ii. Physician responsible for the home health plan of care; iii. Medications the patient is on at the time of discharge; iv. Patient and family post-discharge instructions; v. Patient's discharge condition and needs; vi. Patient outcomes in meeting the goals in the plan of care; and vii. Patient and family post-discharge instructions. During a face-to-face interview with Employee #5, the Clinical Manager who is a registered nurse on 05/12/2022 at approximately 3:20 PM, she acknowledged and confirmed the findings.

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 interviews with agency staff, review of 10 clinical records and the agency's policy, the agency's clinician failed to ensure individualized plans of care included all required elements in one (1) of 10 clinical records (Patient #6). Findings included: A review of the Home Health Agency's policy, reference number 196, titled “Physician Plan of Care Orders” show that the Plan of care will include primary and secondary diagnoses, Safety measures, medications and so on. The surveyor conducted a review of Patient#6’s clinical record on 05/12/2022 at approximately 3:20 PM that showed a Plan of Care for Skilled Services with a Start of Care date of 01/15/2022, and a Recertification Period of 03/16/2022 to 05/14/2022. The diagnoses listed on the Plan of Care included Cerebrovascular Disease, Osteoarthritis, Chronic Ischemic Heart Disease, Disorder of Done Density and Structure, Peripheral Vascular Disease, Leg Pain, Atrial Fibrillation, and Essential Hypertension. Additional review of the current Plan of Care showed the item titled 'Medications' detailed a list that included: a. Trintellix usually prescribed for treatment of Major Depressive Disorder; b. Levetiracetam usually prescribed for treatment of seizures; c. Pravastatin Sodium usually prescribed for treatment of cholesterol and triglycerides; d. Famotidine usually prescribed for to prevent intestinal ulcers; The Plan of Care did not include i. All pertinent diagnoses associated with indications for the aforementioned prescribed medications; ii. Safety measures to protect against injury associated with the potential for bleeding, cuts that take longer than usual to stop bleeding. Nosebleeds, or bruising more often than usual associated with Clopidogrel. iii. 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; and iv. Patient and caregiver education and training to facilitate timely discharge. During a face-to-face interview with Employee #5, the Clinical Manager and registered nurse on 05/12/2022 at approximately 3:20 PM, she acknowledged and confirmed the findings.

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 review and revise of the plan of care to reflect any verbal order received during the certification period so that all HHA staff are working from a current plan in one (1) of ten (10) clinical records (Patients #1). Findings included: A review of the Home Health Agency's policies did not include “All patient care orders, including verbal orders, must be recorded in the plan of care…” The surveyor conducted a review of Patient #1’s clinical record on 05/24/2022 at approximately 3:30 PM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 04/15/2014, and an annual Recertification Period of 04/01/2022 - 03/31/2023. The diagnoses listed on the Plan of Care included Heart Failure, Abnormalities of Gait, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Asthma, Obesity due to Excess Calories, Human Immunodeficiency Virus, Type II Diabetes, Gastroesophageal Reflux, Bipolar Disorder, and Cholelithiasis. Additional review of the clinical record showed verbal orders dated 04/12/2022, and 05/02/2022 that were not recorded in the current plan of care. The verbal orders dated 04/12/2022 included notification to the patient’s primary care physician regarding a change in the patient’s status and request for wound care orders. The verbal orders dated 05/02/2022 included additional durable medical equipment; a manual wheelchair and PERS (Personal Emergency Response) unit. In addition, the order stipulates patient goals and patient likes and wishes. The surveyor conducted a face-to-face interview with Employees #1(Administrator), and #2 (Clinical Manager), both Registered Nurses who acknowledged and confirmed the findings on 05/25/2022 at approximately 1.00 PM.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of ten (10) clinical records, the agency's policies, and interview with agency staff, the agency's staff failed to prepare complete written patient care instructions for a home health aide in one patient receiving Personal Care Aide Services only (Patient # 1). Findings included... A review of the Home Health Agency's un-numbered policy, titled "HHA/ PCA Orientation/ Inservice", shows that the Aides are instructed to ensure that they are following the "HHA/ PCA Plan of Care" developed by the the patient's nurse or therapist. The surveyor conducted a review of Patient #1's clinical record on 05/09/2022 at approximately 2:15 PM that showed a Plan of Care for Personal Care Aide Services with a Start of Care date of 04/15/2014, and an annual Recertification Period of 04/01/2022 to 03/31/2023. The diagnoses listed on the Plan of Care included Heart Failure, Osteoarthritis, Abnormalities of Gait, Chronic Obstructive Pulmonary Disease, Asthma, Morbid Obesity due to Excess Calories, Human Immunodeficiency Virus, Type II Diabetes, Gastroesophageal Reflux, Bipolar Disorder, and Cholelithiasis. Physician orders on the current Plan of Care directed the skilled nurse to visit the patient 2 to 5 times a month to assess and observe all body systems, and 3 visits as needed until the end of certification period. In addition, the physician orders on the current Plan of Care directed Personal Care Aide services; 12 hours for 7 days each week until the end of certification period. Patient #1 received 12 hours on Saturdays and Sundays, and 4 to12 hours on weekdays. The physician orders also stipulate the patient prefers male aides, and direct the aides to assist the patient with Activities of Daily Living including bathing, dressing, eating, feeding, grooming, meal preparations, transfers, mobility/ambulation, light housekeeping, laundry, errands, reminders to take medications, and accompanying the patient to medical appointments, as needed. Further review of the clinical record showed Employee #6, a registered nurse reviewed the written patient care instructions for the home health aide, referred to as the ‘Home Health Aide-Patient Care Plan’ for Patient #1 on 04/22/2021. Continued review of the clinical record showed Employee #6, prepared an annual Recertification Comprehensive Assessment with OASIS elements dated 04/12/2022. The assessment shows Patient #1 was morbidly obese, incontinent of bowel and bladder, intolerant of endurance, ambulation, and minimal exertion. The surveyor's review of Patient #1's Recertification Comprehensive Assessment dated 04/12/2022, reflected the patient was bed- bound, homebound and required someone to assist with grooming, putting on upper body clothing, undergarments, slacks, socks or nylons, and shoes. The assessment also showed the patient would also require someone to help maintain toileting hygiene and/or adjust clothing. Also, Employee #6 noted that Patient #1 “…was at high risk for skin breakdown due to poor oxygen perfusion(HF), DM2, incontinence of bowel and bladder, morbid obesity, immobility, inability to change positions, frictions and sharing during care giving and poor nutrition...”, assessed the patient as being unable to participate effectively in bathing and required to be bathed totally by another person. The patient was also unable to get to and from the toilet but was able to use a bedside commode. The registered nurse failed to prepare complete written patient care instructions for the home health aide to include turning and repositioning the patient in bed. The surveyor conducted a face-to-face interview with Employee #5, the Clinical Manager, a registered nurses who acknowledged and confirmed the findings on 05/24/2022 at approximately 3: 30 PM.