Every finding on record at Presidential Healthcare at Home LLC

ACTS Reference #6N2I-006 A CMS authorized Complaint Survey was completed on 4/04/22 to determine compliance with the following Federal Conditions of Participation related to Home Health Agencies: - CFR 484.10 Patient Rights - CFR 484.60 Care Planning, Coordination of Services and Quality of Care - CFR 484.70 Infection Prevention and Control - CFR 484.75 Skilled Professional Services The agency was found to be at Standard Level non-compliance and a Statement of Deficiency was generated in conjunction with the investigation of this complaint.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interviews and records reviewed, for one of three sampled patients (Patient #1), the Home Health Agency (HHA #1, the original agency that accepted Patient #1 to its caseload) failed to ensure Patient #1 received scheduled skilled nursing and physical therapy visits between 1/14/22 and 1/19/22, as ordered by his/her physician in accordance with the plan of care. Finding include: Review of Patient #1’s Home Health Plan of Care and Certification, dated 12/05/21, indicated Patient #1 lived in an assisted living facility (ALF) and was without a caregiver for necessary wound care. The Plan of Care and Certification indicated Patient #1's physician ordered HHA #1 to provide one skilled nursing visit for wound care weekly and up to two visits as need for the certification period from 12/05/21 through 2/02/22. Review of Patient #1’s medical record indicated that per his/her Physical Therapy Plan of Care, dated 1/10/22, indicated Patient #1's physician orders indicated he/she had physician orders to receive HHA #1 physical therapy treatments two times per week for four weeks for a home exercise program, transfer, gait, and balance training. Review of Patient #1’s Skilled Nurse Visit Note, dated 1/10/22, indicated Patient #1 received wound care for a left heel pressure injury. The Note indicated the pressure injury measured 3.5 centimeters (cm) by 2.5 cm and had minimal serosanguinous drainage (yellow drainage with blood in it). The Note indicated Patient #1’s next scheduled skilled nursing visit was 1/12/22. Review of Patient #1’s Skilled Nurse Visit Note, dated 1/12/22, indicated Patient #1 was seen by the podiatrist during the skilled nursing visit. The Note indicated there were no signs or symptoms of infection and the left heel pressure injury was treated with NS (Normal Saline) wash, apply Aquacel Ag dressing (a hydrofiber dressing with silver) with borders. The Note indicated the goal for the HHA agency services was for Patient #1 to be discharged from HHA #1 when his/her wound healed. The Note indicated Patient #1's next scheduled skilled nursing visit was 1/14/22. Review of the Schedule in Patient #1’s electronic health record indicated that although Patient #1 had skilled nursing visits scheduled for 1/14/22, 1/17/22 and 1/19/22 and a physical therapy visit scheduled for 1/14/22, Patient #1’s visits were placed on hold effective 1/14/22 per the Administrator. During interviews on 4/04/22 at 10:00 A.M., the Administrator and Director of Nursing said that Patient #1’s skilled nursing and physical therapy visits were placed on hold as of 1/14/22 after the ALF staff members told the Director of Nursing that Patient #1 tested positive for COVID-19. The Administrator and Director of Nursing said that HHA #1 had a policy which prohibited staff members from seeing patients who had COVID-19. Review of the untitled Policy and Procedures Urgent/Important, dated 4/07/20, indicated that to ensure the safety of caregivers and patients, patients who test positive for COVID-19 must complete quarantine as recommended by the CDC and could resume care once the quarantine ended. The Director of Nursing said that the HHA #1 did not conduct Patient #1's scheduled skilled nursing and physical therapy visits on 1/14/22, 1/17/22 and 1/19/22, in accordance with his/her plan of care.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on interviews and records reviewed for one of three sampled patients (Patient #1), the Home Health Agency (HHA #1) failed to arrange a safe and appropriate transfer to other care entities after placing Patient #1’s physician ordered skilled nursing visits for wound care and physical therapy visits on hold on 1/14/22 after Patient #1 tested positive for COVID-19. On 1/17/22 after Patient #1 missed two skilled nursing visits and one physical therapy visit, the Resident Care Director of the assisted living facility (ALF) where Patient #1 resided, arranged for Patient #1's skilled nursing visits transferred to another home health agency. Findings include: Review of Patient #1’s Home Health Plan of Care and Certification, dated 12/05/21, indicated Patient #1 lived in an ALF and was without a caregiver to complete his/her wound care. The Plan of Care and Certification indicated Patient #1's physician ordered HHA #1 to provide one skilled nursing visit for wound care weekly and up to two visits as need for the certification period from 12/05/21 through 2/02/22. Review of Patient #1’s medical record indicated that per his/her Physical Therapy Plan of Care, dated 1/10/22, he/she had physician orders to receive HHA #1 physical therapy treatments two times per week for four weeks for a home exercise program, transfer, gait, and balance training. Review of Patient #1’s Skilled Nurse Visit Note, dated 1/10/22, indicated Patient #1 received wound care for a left heel pressure injury. The Note indicated the pressure injury measured 3.5 centimeters (cm) by 2.5 cm and had minimal serosanguinous drainage (yellow drainage with blood in it). The Note indicated Patient #1’s next scheduled visit was 1/12/22. Review of Patient #1’s Skilled Nurse Visit Note, dated 1/12/22, indicated Patient #1 was seen by the podiatrist during the skilled nursing visit. The Note indicated there were no signs or symptoms of infection and the left heel pressure injury was treated with NS (Normal Saline) wash, apply Aquacel Ag dressing (a hydrofiber dressing with silver) with borders. The Note indicated the goal for Agency services was for Patient #1 to be discharged from HHA #1 when his/her wound healed. The Note indicated Patient #1's next scheduled skilled nursing visit was 1/14/22. Review of the Schedule in Patient #1’s electronic health record indicated that although Patient #1 had skilled nursing visits scheduled for 1/14/22, 1/17/22 and 1/19/22 and a physical therapy visit scheduled for 1/14/22, Patient #1’s visits were placed on hold effective 1/14/22 per the Administrator. During interviews on 4/04/22 at 10:00 A.M., the Administrator and Director of Nursing said that Patient #1’s skilled nursing and physical therapy visits were placed on hold as of 1/14/22 after the ALF staff members told the Director of Nursing that Patient #1 tested positive for COVID-19. The Administrator and Director of Nursing said that the Agency (HHA #1) had a policy which prohibited staff members from seeing patients who had COVID-19. The Administrator and the Director of Nurses said that the Agency (HHA #1) did not arrange for Patient #1's immediate transfer to another agency that was capable of providing his/her wound care and physical therapy after his/her COVID-19 diagnosis. During an interview on 4/07/22 at 12:45 P.M., the Resident Care Director said that on 1/17/22 the ALF Care Manager told her that Patient #1’s wound was getting worse and, when the Resident Care Director called HHA #1 to discuss the wound, HHA #1 told her that they were not providing services for Patient #1 because he/she tested positive for COVID-19. Review of a Progress Note dated 1/17/22 in Patient #1's ALF record indicated the ALF Care Manager told the Resident Care Director that Patient #1's coccyx wound was getting worse and the Resident Care Director communicated with HHA #1. The Note indicated HHA #1 told the Resident Care Director that they could not enter the room of a COVID-19 positive patient. The Note indicated the Resident Care Director spoke to Patient #1's family member, Patient #1's physician and to HHA #2 and arranged for HHA #2 take over Patient #1's skilled nursing visits for wound care. The Residential Care Director said that she contacted Patient #1’s family member on 1/17/22 and the family member agreed to switch Patient #1’s services to another Agency (which going forward will be referred to as HHA #2). The Resident Care Director said that she contacted Patient #1's physician and HHA #2 and arranged for HHA #2 to provide skilled nursing visit for Patient #1 as soon as possible due to Patient #1’s urgent need for wound care. The Resident Care Director said that on 1/19/22, HHA #2 notified her that although they received the referral from Patient #1’s physician, they could not start Patient #1's home care because HHA #1 had not discharged Patient #1. During interviews on 4/07/22 at 12:45 P.M. and 4/14/22 at 9:53 A.M., the Clinical Director of HHA #2 said that on 1/19/22 when HHA #2 received a referral from Patient #1's physician for skilled nursing services for Patient #1, HHA #2 checked Patient #1's insurance eligibility and determined that HHA #1 had not discharged Patient #1. The Clinical Director of HHA #2 said that Medicare prohibited a home health agency from initiating home health services for a patient if the services duplicated services in place by another home health agency. The Clinical Director of HHA #2 said that on 1/19/22, they called the Administrator of HHA #1 and he said he would complete a non-desk visit discharge for Patient #1 as of 1/19/22. Review of Patient #1's Eligibility Coverage Detail Report, dated 4/14/22, indicated that Patient #1 was discharged from HHA #1 on 1/20/22. The Resident Care Director of the ALF and the Clinical Director of HHA #2 said a skilled nursing visit for wound care was finally conducted for Patient #1 on 1/20/22, however that was six days after HHA #1 placed Patient #1's skilled nursing visits on hold due to him/her testing positive for COVID-19.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interviews and records reviewed, for one of three sampled patients (Patient #1) the Home Health Agency (HHA #1) failed to investigate a complaint when the Executive Director of the Assisted Living Facility (ALF) where Patient #1 resided, emailed the Administrator that due to a lack of communication between HHA #1 and the ALF about Patient #1's missed skilled nursing visits, Patient #1's wounds had worsened. HHA #1 (administration) did not initiate an investigation and instead responded by emailing the ALF Executive Director to stop corresponding with him or he would seek legal action for harassment. Findings include: Review of the Home Health Agency Complaints and Grievances Policy for HHA #1, dated 2022, indicated that HHA #1 must investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family. The Policy indicated that the Agency would document the existence of the complaint and the resolution of the complaint. The Policy indicated that the responsibilities of the Agency included: documenting the grievance, whether written or verbal, in the patient's clinical record by the Administrator or his designee; documenting the resolution of the problem in the same manner; responding to each written grievance in writing by the Agency within ten days; interviewing of each person involved by the Administrator; after a thorough evaluation, the Administrator makes a determination, formulates a decision, and notifying all persons involved; all information regarding activities, investigation, analysis, resolution and outcomes is documented in the patient's chart; a copy or the outcome is to be filed in the patient's clinical record. The Complaints and Grievances Policy for HHA #1 indicated that the Agency must investigate complaints, including but not limited to, the treatment or care that is (or fails to be) furnished, is furnished inconsistency, or is inappropriately furnished. Review of Patient #1’s Home Health Plan of Care and Certification, dated 12/05/21, indicated Patient #1 resided in an ALF. The Home Health Plan of Care and Certification indicated that Patient #1 #1 was approved from 12/05/21 to 2/02/22 to receive weekly and as needed skilled nursing visits for assessment, evaluation and teaching regarding wound care during the certification period. Review of Patient #1’s Physical Therapy Plan of Care, dated 1/10/22, indicated Patient #1's physician added an order to Patient #1's care plan for HHA #1 to provide physical therapy treatments two times per week for four weeks for a home exercise program and transfer, gait and balance training. During an interview with the ALF Executive Director on 4/05/22 at 12:48 P.M. the Executive Director said that Patient #1 lived at the ALF and HHA #1 had provided skilled nursing visits for Patient #1 during December 2021 and January 2022. The ALF Executive Director said that unbeknownst to the ALF, HHA #1 stopped seeing Patient #1 when Patient #1 tested positive for COVID-19 on 1/12/22. The ALF Executive Director said that the ALF was not aware that HHA #1 had not provided skilled nursing visits which included wound care for Patient #1 until nursing staff of the ALF observed that Patient #1's wounds worsened. The ALF Executive Director said that she called and emailed the Administrator of HHA #1 several times during February 2022 to discuss the lack of communication between HHA #1 and the ALF when HHA #1 stopped seeing Patient #1 and the impact that the missed skilled nursing visits for wound care had on Patient #1's wounds. The ALF Executive Director said that the Administrator did not respond to her telephone calls. The ALF Executive Director said that on 2/08/22, the Administrator of HHA #1 sent her an email which indicated she should stop corresponding with him or he would seek legal action for harassment. Review of the ALF Executive Director’s email correspondence dated 2/08/22, indicated that the ALF Executive Director emailed the Administrator of HHA #1 about Patient #1. The Email indicated that the ALF Executive Director informed the Administrator that the ALF had not been notified that HHA #1 stopped providing services to Patient #1 after HHA #1 refused to see Patient #1 because he/she tested positive for COVID-19. The Email indicated the ALF Executive Director informed the Administrator of HHA #1 that Patient #1’s wounds had not been looked at for close to a week and worsened from a stage II to stage IV. (A Stage II Pressure Ulcer is a partial-thickness loss of skin with exposed dermis and presents as a shallow, open ulcer or open/ruptured blister. A Stage IV Pressure Ulcer is a full-thickness loss of skin and tissue with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.) Review of the ALF Executive Director’s email correspondence dated 2/10/22 indicated that the Administrator of HHA #1 replied to the Executive Director via email and indicated that he had received the Executive Director's emails and telephone calls, that HHA #1 was not obligated to answer the Executive Director’s questions and allegations, and, that if the Executive Director continued to contact HHA #1, HHA #1 would file a harassment suit against the Executive Director. Review of a Letter dated 2/03/22 from the Certification Specialist at the Executive Office of Elder Affairs to the Department of Public Health indicated that the Executive Office of Elder Affairs received an incident report on 1/22/22 regarding Patient #1's worsening condition and an interruption to his/her skilled nursing visits provided by HHA #1 after Patient #1 tested positive for COVID-19 at the ALF. The Letter indicated the Certification Specialist contacted HHA #1 on 1/27/22 and 2/01/22 to verify the practice of suspending skilled nursing visits when patients tested positive for COVID-19 and HHA #1 did not respond. During an interview with the Administrator and the Director of Nursing at 10:00 A.M on 4/04/22, that Surveyor requested to review written documentation related to complaints about HHA #1's care of Patient #1. The Administrator said that HHA #1 had not received any complaints about Patient #1’s care and the Administrator said he was not able to provide any documentation to support that HHA #1 investigated any complaints about Patient #1's care.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on interviews and records reviews, for one of three sampled patients (Patient #1), the Home Health Agency (HHA #1) failed to communicate revisions to Patient #1's care plan to Patient #1’s caregiver when on 1/14/22, HHA #1 placed Patient #1’s skilled nursing and physical therapy visits on hold after Patient #1 tested positive for COVID-19 and HHA #1 did not notify the Assisted Living Facility (ALF) where Patient #1 resided that Patient #1's services were on hold. Findings include: Review of Patient #1’s Home Health Plan of Care and Certification, dated 12/05/21, indicated Patient #1 lived in an assisted living facility (ALF) and was without a caregiver for necessary wound care. Review of the Plan of Care and Certification indicated HHA #1 had s physician's orders to provide Patient #1 with one skilled nursing visit for wound care weekly and up to two visits as needed during the 12/05/21 through 2/02/22 certification period from. Review of Patient #1’s Physical Therapy Plan of Care, dated 1/10/22, indicated HHA #1 had physician's orders to provide Patient #1 with physical therapy treatments two times per week for four weeks for a home exercise program and transfer, gait and balance training. Review of Patient #1’s Skilled Nurse Visit Note, dated 1/10/22, indicated Patient #1 received wound care for a left heel ulcer. The Note indicated the pressure injury measured 3.5 centimeters (cm) by 2.5 cm and had minimal serosanguinous drainage (yellowish drainage with small amounts of blood). The Note indicated Patient #1’s next scheduled visit was 1/12/22. Review of Patient #1’s Skilled Nurse Visit Note, dated 1/12/22, indicated Patient #1 was seen by the podiatrist during the skilled nurse visit. The Note indicated there were no signs or symptoms of infection and the left heel pressure injury was treated with NS (Normal Saline) wash, apply Aquacel Ag dressing (a hydrofiber dressing with silver) with borders. The Note indicated the goal was for Patient #1 to be discharged from HHA #1 when his/her wound healed, and that his/her next scheduled visit was 1/14/22. Review of the Schedule in Patient #1’s electronic health record indicated that although Patient #1 had skilled nursing visits scheduled on 1/14/22, 1/17/22 and 1/19/22 and had a physical therapy visit scheduled for 1/14/22, Patient #1’s visits were placed on hold effective 1/14/22 per the Administrator and Patient #1’s family and physician were notified. During an interview on 4/04/22 at 10:00 A.M., the Director of Nursing said that when she attempted to make Patient #1’s skilled nurse visit on 1/14/22, staff members of the ALF told her that Patient #1 had tested positive for COVID-19. The Director of Nursing said that she told the Resident Care Director of the ALF that HHA #1 had a policy against seeing patients who had COVID-19. Although the Director of Nursing said she told the Resident Care Director of the ALF that HHA #1 placed Patient #1's skilled nursing visits on hold after Patient #1 tested positive for COVID-19, there was no documentation in HHA #1's clinical record for Patient #1 to support that the Director of Nursing told the Resident Care Director of the ALF that Patient #1's services were on hold. During an interview on 4/07/22 at 12:45 P.M., the Resident Care Director of the ALF said that HHA #1 did not inform her that Patient #1’s services were placed on hold on 1/14/22. The Resident Care Director said that on 1/17/22 the ALF Care Manager told her that Patient #1’s wound was getting worse and the Resident Care Director called HHA #1. The Resident Care Director said that when she called HHA #1 the Director of Nurses told her that HHA #1 was not providing skilled nursing visits for Patient #1 because they could not go into the room of a patient who tested positive for COVID-19. Review of a Progress Note in Patient #1's ALF record, dated 1/17/22, indicated the ALF Care Manager informed the Resident Care Director that Patient #1's coccyx wound was getting worse and the Resident Care Director called HHA #1. The Note indicated HHA #1 told the Resident Care Director that the staff of HHA #1 could not enter Patient #1's room because he/she tested positive for COVID-19. During an interview on 4/08/22 at 9:49 A.M., Nurse #1 said that she was Patient #1’s nurse at the ALF on 1/12/22 and 1/14/22. Nurse #1 said that Patient #1 tested positive on 1/12/22 for COVID-19, but said the test was conducted after his/her visit from HHA #1 for skilled nursing services. Nurse #1 said that the Director of Nursing from HHA #1 never told her that HHA #1 had placed Patient #1’s skilled nursing and physical therapy visits on hold after Patient #1 tested positive for COVID-19. Review of Patient #1's Progress Notes for 1/12/22 and 1/14/22 written by Nurse #1 indicated there was no evidence to support the Director of Nurses informed Nurse #1 that HHA #1 would not be providing Patient #1's skilled nurse visits because he/she tested positive for COVID-19.