Every finding on record at Sincere Home Health Care Inc

A recertification survey was conducted on 10/28/2024. The census was 39 Licensed and Certified patients. The agency was in compliance with the Conditions of Participation for Emergency Preparedness for Home Health Agencies.

A recertification survey was conducted on 10/28/2024. The census was 39 Licensed and Certified patients. Abbreviations: DON – Director of Nurses / Supervising Nurse PIP- Performance Improvement Project

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview the home health agency failed to conduct any performance improvement projects for 2021, 2022, 2023, and through the survey date October 31, 2024. Agency patients were potentially subjected to substandard care. Review of the quality assurance documents provided by the agency Administrator on 10/31/2024 revealed a report for 2021 dated 11/21/2021which read in part on page 4 of 4: “Agency has not identified PIP.” Review of the quality assurance documents provided by the agency Administrator on 10/31/2024 revealed a report for 2022 dated 03/ 05/2023 which read in part on page 4 of 4: “Agency has not identified PIP.” Review of the quality assurance documents provided by the agency Administrator on 10/31/2024 revealed a report for 2023 dated 02//27/2024 which read in part on page 4 of 4: “Agency has not identified PIP.” Review of the quality assurance documents provided by the agency Administrator on 10/31/2024 revealed a report for 2024 dated 04/16/2024 which read in part on page 4 of 4: “Agency has not identified PIP.” A review of all the quality assurance documents provided by the agency revealed no evidence of the identification and completion of Performance Improvement Projects. An interview was conducted with the DON on 10/31/2024 1:00 PM. The surveyor reviewed the findings from the quality assurance record reviews and asked about Performance Improvement Projects. The DON stated they didn’t do any. The surveyor asked the DON who was responsible for the quality assurance program. The DON stated she did the reports quarterly. The surveyor asked who was on the quality assurance committee. The DON described the participants as herself, the Administrator, another nurse, and sometimes a therapist. The surveyor asked why the agency had not chosen to identify and conduct any performance improvement projects for the last three years. The DON stated she didn’t know to do them. An interview was conducted with the Administrator on 10/31/2024 at 1:35 PM. The surveyor reviewed the findings from the quality assurance record reviews and Performance Improvement Projects. The surveyor asked who was responsible for the quality assurance program and performance improvement projects. The Administrator stated the DON was responsible to prepare the reports and provided the reports to him. The surveyor asked about the Performance Improvement projects. The Administrator stated: “They weren't done and that would be basically on the clinical side.” The Administrator stated: “I basically tried to rely on the DON to give me the feedback on what needs to be done because I work with her. “The surveyor asked what happened with the quality assurance reports once the DON prepared them. The Administrator stated: “We sit down together with my alternate administrator, and we discussed all the issues which we have and how we have to basically move forward.” The Administrator stated: “This is an area where we need to focus on and ignorance is not the excuse because this has been there for this many years, as you're telling me. “The surveyor asked what the Administrator’s role was in quality assurance. The Administrator stated: “I basically make sure that this gets incorporated in the whole process itself, and the reason it (Performance Improvement Projects) hasn't been done is it wasn't brought to my attention. I rely on the DON and that was not communicated to me.” Agency policy titled: Performance Improvement Process QAPI.5 dated 01/13/2018 read in part: “Policy – I. The Governing Body will be responsible for setting the priorities for improvement activities or projects based on Agency functions, the defined data collection, the resources required to facilitate the improvement, and the organization’s mission. II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually… All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved…”

Purpose of visit: Recertification survey Entrance Date: 10/04/2021 at 10:35 AM with the Administrator. Agency Census: 36 Licensed and Certified Home Health -32 Licensed Home Health - 0 Personal Assistance Services - 4 Exit Date: 10/07/2021 at 2:30 PM with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was in substantial compliance with the Conditions of Participation for Emergency Preparedness.

Purpose of visit: Recertification survey Entrance Date: 10/04/2021 at 10:35 AM with the Administrator. Agency Census: 36 Licensed and Certified Home Health -32 Licensed Home Health - 0 Personal Assistance Services - 4 Exit Date: 10/07/2021 at 2:30 PM with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: # - number DON- Director of Nurses POC- Plan of Care PAS - Personal Assistance Services QAPI – Quality Assurance Performance Improvement LVN- Licensed Vocational Nurse EMR – Electronic Medical Record Mm/HG – millimeters of mercury HHA- Home Health Aide RN – Registered Nurse CMS – Centers for Medicare and Medicaid Services

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide 2 (patients 1 and 2) of 2 patients, whose home folders were available for review during home visits, with the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that served the area the 2 patients resided in: Agency on Aging Center for Independent Living Protection and Advocacy Agency, and Aging and Disability Resource Center. This failure prevented the agency patients from accessing and obtaining community services that were not provided by the agency. Findings: On 10/04/2021 the surveyor requested a sample admission packet the agency used for new patient admissions. The surveyor[RM(1] reviewed the sample admission folder provided by the Administrator on 10/05/2021 at 9:30 AM. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The packet contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was left blank with no agency name and no resource center name and no addresses and phone numbers. Record review for Patient 1 revealed a POC dated 09/23/2021 to 11/21/2021 with a start of care date of 09/23/21. The POC listed diagnoses of Primary Osteoarthritis, Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism, Major Depressive Disorder, Sleep Apnea, Presence of Automatic Cardiac Defibrillator, and Dependence on Supplemental Oxygen. The POC listed orders for a skilled nursing visits one time per week for nine weeks. During a home visit with Patient 1 on 10/06/2021 at approximately 11 AM, the surveyor reviewed the home folder provided by the agency to Patient 1. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The packet contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was left blank with no agency name and no resource center name and no addresses and phone numbers. Record review for Patient 2 revealed a POC dated 08/05/21 to 10/03/21 with a start of care date of 08/05/21. The POC listed diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Type 2 Diabetes Mellitus with Diabetic Cataract, Polyosteoarthritis, Idiopathic Gout, Iron Deficiency Anemia, Morbid Obesity, and Dependence on Supplemental Oxygen. The POC listed orders for a skilled nursing visits one time per week for nine weeks. During a home visit with Patient 2 on 10/06/2021 at approximately 11:30 AM, the surveyor reviewed the home folder provided by the agency to Patient 2. Review of all the documents in the sample admission packet revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The packet contained a form titled: “Contact Information for Agency Name and Federal and State Public Agencies which had areas to complete the Protection and Advocacy Agency Name, address and phone number, and Aging and disability Resource Center name, address and phone number. The form was left blank with no agency name and no resource center name and no addresses and phone numbers An interview was conducted with the Administrator and DON on 10/06/21 at 2:40 PM. The surveyor shared the results of the sample home folder and home visit folder reviews. The surveyor noted the sample and home folders did not contain the names, addresses, and telephone numbers of the Federally funded and state-funded entities that served the areas the patients resided in. The Administrator stated: “We have to fill it out.” No additional information to correct or clarify the findings was provided by the end of the survey. Agency policy review of the policy titled: “Patient/Client Rights and Responsibilities…RI.1” dated 011318 read in part: “Agency staff will be responsible for knowing, observing, and implementing the patient’s/client’s rights, patient/client conduct and patient/client responsibilities on an ongoing basis… The patient/client has the right to:…Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that service area where the patient/client resides: 1. Agency on Aging,2. Center for Independent Living, 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization…”

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 review and interview, the agency failed to ensure the patients' plan of care was complete and included all the required elements including 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 for 7 (patients 1,2,3,4,5,6 and 7) of 7 records reviewed. These failures placed patients at risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions. Findings: Record review for patient 1 revealed a POC dated 09/23/2021 to 11/21/2021 with a start of care date of 09/23/21. The POC listed diagnoses of Primary Osteoarthritis, Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism, Major Depressive Disorder, Sleep Apnea, Presence of Automatic Cardiac Defibrillator, and Dependence on Supplemental Oxygen. The POC listed orders for a skilled nursing visit one time per week for 9 weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for patient 2 revealed a POC dated 08/05/21 to 10/03/21 with a start of care date of 08/05/21. The POC listed diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Type 2 Diabetes Mellitus with[RM(1] Diabetic Cataract, Polyosteoarthritis, Idiopathic Gout, Iron Deficiency Anemia, Morbid Obesity, and Dependence on Supplemental Oxygen. The POC listed orders for a skilled nursing visits one time per week for nine weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for patient 3 revealed a POC dated 07/18/21 to 09/15/21 with a start of care date of 05/19/21. The POC listed diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Multiple Sclerosis, Autoimmune Thyroiditis, Irritable Bowel Syndrome, Vitamin D Deficiency, Arthropathic Psoriasis, Difficulty in Walking, and Deficiency of other Specified B Group Vitamins. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for patient 4 revealed a POC dated 8/04/21 to 10/02/21 with a start of care date of 08/04/21. The POC listed diagnoses of Hypothyroidism, Essential Hypertension, Primary Generalized Osteoarthritis, Hyperlipidemia, Simple Chronic Bronchitis, Bilateral Temporomandibular Joint Disorder, Chronic Kidney Disease, Personal History of Other Malignant Neoplasm of Large Intestine, Erythema Intertrigo. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for patient 5 revealed a POC dated 09/11/21 to 11/09/21 with a start of care date of 07/13/21. The POC listed diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Hypertension, Type 2 Diabetes Mellitus, Age Related Osteoporosis without current Pathological Fracture, Unspecified Dementia, Hyperlipidemia, Urinary Incontinence, Dysthymic Disorder, Muscle Weakness, Unsteady on Feet, Long Term Use of Oral Hypoglycemic Drugs, Long Term use of Aspirin Post-Traumatic Osteoarthritis of Knee, and Type 2 Diabetes Mellitus. The POC listed orders for skilled nursing one time per week for nine weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for patient 6 revealed a POC dated 07/08/21 to 09/05/21 with a start of care date of 03/10/21. The POC listed diagnoses of Type 2 Diabetes Mellitus, Essential Hypertension, Hypothyroidism, Hyperlipidemia, Lower Abdominal Pain, Chronic Kidney Disease, and Gastro-Esophageal Reflux Disease. The POC listed orders for skilled nursing one time per week for nine weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. Record review for patient 7 revealed a POC dated 12/08/20 to 02/05/21 with a start of care date of 10/08/20. The POC listed diagnoses of Overactive Bladder, Essential Hypertension, Urinary Incontinence, Unspecified Dementia, Primary Generalized Arthritis, Hyperlipidemia, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Personal History of Transient Ischemic Attack, Cerebral Infarction without Residual Deficits, and Low Back Pain. The POC listed orders for skilled nursing one time per week for nine weeks. The POC did not contain a description of the patient's risks for emergency department visits and hospital re-admissions and all necessary interventions to address the underlying risk factors. An interview was conducted with the Administrator and DON, on 10/06/21 at 2:00 PM. The surveyor shared the results of the clinical record reviews and home visits for patients 1 – 7. The surveyor noted the POCs did not contain 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. The Administrator stated “OK, I didn’t know.” A review of the agency policy titled: “Plan of Care TX.4” dated 0113118 read in part: “The individualized plan of care must include the following: … A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors…”

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to integrate services with all providers and to enforce their written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of services between the agency and all providers involved in the care of patients for 3(#1, #3, and #4) of 5 active patient records reviewed. Patient #1 and Patient #4 had blood pressure results that were outside the ordered parameters that were not reported to the physician, Patient # 3 received PAS services from another provider and the records contained no evidence of integration of services and coordination with the PAS provider. These failures placed the agency patients at risk of harm, when the agency’s staff failed to integrate services with all providers, due to the lack of shared information regarding the ongoing care, and changes in service needs of the patients. FINDINGS: A review of Agency policy, dated 08/01/2020, read in part, "Monitoring Patient Care/ Coordination of Care, ... Purpose: To ensure the effective exchange of information, reporting and coordination of patient/client services.... Procedure: ... B. Coordination of care will occur between other providers of care, including... a physician, another agency... an outpatient facility... When other organizations are involved in the patient’s/client’s care, Agency staff members will notify them of significant changes in the patient’s /client’s overall care. The communication will be documented in the medical record…Skilled professional who provide services to Agency patients/clients directly or under arrangement must participate in the coordination of care. Effective interchange and reporting, as well as collaboration and coordination of care will occur between all Agency personnel provider care, whether the care and services are provided directly or under arrangement[…” Patient 1 Record review for patient 1 revealed a POC dated 09/23/2021 to 11/21/2021 with a start of care date of 09/23/21. The POC listed diagnoses of Primary Osteoarthritis, Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism, Major Depressive Disorder, Sleep Apnea, Presence of Automatic Cardiac Defibrillator, and Dependence on Supplemental Oxygen. The POC listed orders for a skilled nursing visit one time per week for 9 weeks, and an order to notify the physician of significant changes that warrant treatment plan of care modification including: Diastolic Blood Pressure of less than 60 mm/HG. The skilled nurse visit note dated 09/28/21 signed by the LVN A documented the patient’s blood pressure was 106/56. LVN A documented that the MD was not contacted on the visit note. A review of the record revealed no evidence of contact to the physician to report the significant change in the patient’s condition as ordered. An interview was conducted with the Administrator and DON on 10/06/21 at 2:00 PM to review the clinical record reviews and home visit findings. The surveyor shared the findings for Patient #1. The DON stated the nurse should have[RM(2] called the doctor and documented it on the clinical note or a communication note. The DON reviewed the record and stated: “It’s not there.” Patient 3 A home visit was conducted on 10/05/2021 at approximately 1:45 PM with Patient #3. The patient stated she received services 6 days a week from the PAS provider AA for assistance with bathing, dressing, grooming, and homemaker services for several years. Record review for Patient 3 revealed a POC dated 07/18/21 to 09/15/21 with a start of care date of 05/19/21. The POC listed diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Multiple Sclerosis, Autoimmune Thyroiditis, Irritable Bowel Syndrome, Vitamin D Deficiency, Arthropathic Psoriasis, Difficulty in Walking, and Deficiency of other Specified B Group Vitamins. The recertification reassessment dated 07/13/2021 documented no supportive assistance agencies were providing services. A review of the clinical record revealed no evidence of coordination of services or communication with Patient #3’s PAS provider. An interview was conducted with the Administrator and DON on 10/06/21 at 2:32 PM to review the clinical record review and home visit findings. The surveyor shared the findings for Patient #3 that there was no evidence of coordination of services with the PAS provider. The DON stated: “We call the agency when she is not happy.” The surveyor presented the above findings of where this was documented. The DON stated: “It was verbally done. We need to document. It should have been done.” Patient 4 Record review for patient 4 revealed a POC dated 8/04/21 to 10/02/21 with a start of care date of 08/04/21. The POC listed diagnoses of Hypothyroidism, Essential Hypertension, Primary Generalized Osteoarthritis, Hyperlipidemia, Simple Chronic Bronchitis, Bilateral Temporomandibular Joint Disorder, Chronic Kidney Disease, Personal History of Other Malignant Neoplasm of Large Intestine, Erythema Intertrigo. The POC listed orders for skilled nursing visits one time per week for nine weeks. and an order to notify the physician of significant changes that warrant treatment plan of care modification including: Systolic Blood Pressure more than 160 and Diastolic Blood Pressure more than 90 mm/HG. The skilled nurse note dated 08/04/21 signed by the RN, Identifier B documented the patient’s blood pressure was 160/94. A review of the record revealed no evidence of contact to the physician to report the significant change in the patient’s condition as ordered. An interview was conducted with the Administrator and DON on 10/06/21 at 2:15 PM to review the clinical record review. The surveyor shared the findings for Patient #4 that there was no evidence of a report to the physician regarding the patient’s high blood pressure result. The DON stated: “OK. We will look for it.” No additional information was provided by the end of the survey to explain or correct the findings.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct any Performance Improvement Projects for 3 (2018, 2019, and 2020) of three years of the survey review period. This failure placed the agency's patients at risk of receiving inadequate care and services that could lead to negative health outcomes. Findings: The surveyor requested all agency QAPI documents/reports/manuals on 10/04/2021. A white three ring binder labeled: "QAPI" was provided by the Administrator. The surveyor reviewed the records contained in the QAPI binder provided on 10/07/2021. A review of the entire binder revealed no documentation of Performance Improvement Projects for 2018, 2019, and 2020. An interview was conducted on 10/07/2021 at 4:28 PM with the Administrator The surveyor shared the findings of the review of the QAPI policies, plan, and documents provided by the agency. The surveyor stated there was no evidence of Performance Improvement Projects found for 2018, 2019, and 2020. The Administrator replied: “No. They were not done.” The agency did not dispute the survey findings and did not provide any additional documentation to explain or correct the findings. Review of the agency policy and procedures manual revealed a policy titled: “Quality Assessment Performance Program QAPI.1” which read in part: “Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services] and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and measurable progress achieved on these projects…”