Every finding on record at Southeastern Home Care Services of PA, LLC

Based on the findings of an unannounced onsite Medicare and state complaint survey conducted on August 16, 20024, and completed off-site on August 23, 2024, Accentcare Home Health of Central Pennsylvania, it was determined not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of clinical records, agency policies/procedures, and interview with agency staff, the agency failed to provide ordered frequency of skilled care and notify the physician of missed skilled care visits in one (1) of three (3) clinical records (CRs) reviewed (CR#1). Review conducted on August 16, 2024, at approximately 9:45 AM to 11:20 AM, of agency clinical records (CRs) revealed: CR#1, start of care (soc) 6/15/2024, certification period #1 6/15/24 to 8/13/24: Physician Plan of Care orders: "Skilled nurse (SN) 1 visit per week x1 week, two visits per week for 8 weeks, one visit per week for 1 week."; and week of June 30, 2024, to July 6, 2024, no scheduled SN visits. and no missed visits notification sent to physician by agency. Review conducted on August 16, 2024, at approximately 1:50 PM, of agency policies/procedures revealed: Policy HH 2.1.4 Care Planning and Coordination, page 1 “Purpose: … 4. Coordinate care through regular communication among the staff providing care, visit management and scheduling, consistent patient education, and patient incorporation in the care planning process.; … Procedure: 1. The plan of care is ordered by the physician … and contains all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, … and treatments … .”; and HH 2.2.12 Home Care Staffing Guidelines Policy: The Agency manages and administers its resources to meet workload demands and patient-family needs in accordance with current staffing guidelines. … Home Health service agencies … B. If the Agency misses a visit, a treatment, or service as required by the plan of care, then the Agency shall promptly notify the responsible physician/allowed practitioner of such missed treatment or service and any actual or potential clinical impact upon the patient." Interview conducted on August 16, 2023, at approximately 10:00 AM, with agency Clinical Manager revealed no information regarding the missing two SN visits for CR#1 and no documentation for notification of missing visits to CR #1's physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy/procedure, and interview with agency staff, the agency failed to provide ordered frequency of skilled care and notify the physician of missed skilled care visits in one (1) of three (3) clinical records (CRs) reviewed (CR#1). Review conducted on August 16, 2024, at approximately 9:45 AM to 11:20 AM, of agency clinical records (CRs) revealed: CR#1, start of care (soc) 6/15/2024, certification period #1 6/15/24 to 8/13/24: Physician Plan of Care orders: "Skilled nurse (SN) 1 visit per week x1 week, two visits per week for 8 weeks, one visit per week for 1 week."; and week of June 30, 2024, to July 6, 2024, no scheduled SN visits. and no missed visits notification sent to physician by agency. Review conducted on August 16, 2024, at approximately 1:50 PM, of agency policies/procedures revealed: Policy HH 2.1.4 Care Planning and Coordination, page 1 “Purpose: … 4. Coordinate care through regular communication among the staff providing care, visit management and scheduling, consistent patient education, and patient incorporation in the care planning process.; … Procedure: 1. The plan of care is ordered by the physician … and contains all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, … and treatments … .”; and HH 2.2.12 Home Care Staffing Guidelines Policy: The Agency manages and administers its resources to meet workload demands and patient-family needs in accordance with current staffing guidelines. … Home Health service agencies … B. If the Agency misses a visit, a treatment, or service as required by the plan of care, then the Agency shall promptly notify the responsible physician/allowed practitioner of such missed treatment or service and any actual or potential clinical impact upon the patient." Interview conducted on August 16, 2023, at approximately 10:00 AM, with agency Clinical Manager revealed no information regarding the missing two SN visits for CR#1 and no documentation for notification of missing visits to CR #1's physician.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of employee files (EFs), agency policies/procedures, Center for Disease Control (CDC) Guidelines for Tuberculosis screening, and interview with agency staff, the agency failed to ensure direct care workers, prior to consumer contact, that the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for one (1) of three (3) EFs (EF#2); and failed to document onhire TB risk symptom assessments for two (2) of three (3) EFs reviewed (EFs #1, #3). Review conducted on August 16, 2024, at approximately 11:30 AM to 12:45 PM, of agency employee files (EFs) revealed: EF#1 date of hire (doh) 8/8/22, missing onhire Tuberculosis (TB) risk symptom assessment questionnaire (TB-RAQ). EF#2 doh 8/22/22, missing chest x-ray results. EF#3 doh 12/6/21, missing onhire Tuberculosis (TB) risk symptom assessment questionnaire (TB-RAQ) and annual TB-RAQ education for 2022. Review conducted on August 16, 2024, at approximately 12:15 PM, of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, revealed: "...Baseline testing for M. Tuberculosis infection is recommended for all newly hired health care workers [HCWs]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing..." *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). Review conducted on August 16, 2024, at approximately 1:30 PM, of agency policies/procedures revealed: Policy C 5.3 Tuberculosis Screening, page 1, “Procedure: … At hire, prior to patient contact: TB skin test or Interferon-Gamma Release Assay (IGRA)/QuantiFERON-TB Gold/TB Spot test.; … Baseline chest X-ray report for person with a previously positive TB skin test, TB disease treatment, or BCG vaccine history.; … Complete the TB screening questionnaire – all groups require completion.; … page 2 Annually: … Complete the TB screening questionnaire.; “… and page 3 Pennsylvania: 28 Pa Code 611.56 Health Screening (a) and (b)” sections requirements for onhire TB screening of direct care workers and office staff and annual TB-RAQ documentation.; and Job Description/Performance Appraisal, page 3 “III. Compliance Responsibilities 1. Complies with applicable legal responsibilities, standards, policies and procedures including but not limited to those within the Compliance Process, Code of Conduct and HIPAA. 2. Participates in required orientation, Compliance and HIPAA training programs." Interview conducted on August 16, 2024, at approximately 1:30 PM, of agency Clinical Manager confirmed above findings.

Based on the findings of an unannounced, onsite home health agency state re-licensure survey conducted June 5-9, 2023, Accentcare Home Health of Central Pennsylvania was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced, onsite home health agency state re-licensure survey conducted June 5-9, 2023, Accentcare Home Health of Central Pennsylvania was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of clinical records (CR), agency policy, and interview with agency administrator, the agency failed to ensure the plan of treatment was countersigned by the physician within thirty (30) days of the start of the certification period for one (1) of seventeen (17) records reviewed CR #6. Findings include: Review conducted on June 8, 2023, at approximately 1 PM, of clinical records revealed: CR#6, start of care May 5, 2023, certification period: May 5, 2023 - July 3, 2023; Primary Diagnoses: Hypertension, recent cerebral vascular accident, recovery from recent surgery; contained a plan of treatment countersigned by the physician on June 7, 2023. Thirty four (34) days after the start of the certification period. Review conducted on June 8, 2023, at approximately 3:00 PM, of agency policy “Plan of Care HH 2.1.5” under “Procedure” section, item 9. “The plan of care or supplemental orders will be approved, signed, and dated by the certifying physician or allowed practitioner within 60 days of receiving a verbal order or written order and filed in the medical record. Some states require a 30-day or 30 working day timeline for signed orders to be incorporated into the medical record (i.e., CA, GA, IL, NE, OR, PA).” Conducted interview on June 8, 2023, at approximately 1:30 PM, with Agency Administrator shared 4 fax attempts on 5/19/23, 5/22/23, 5/23/23, and 6/5/23 were performed to obtain physician's signature on CR#6 orders and confirmed the above finding.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), agency policy, and interview with administrator, agency failed to complete wound measurements/dimensions in one (1) out of seventeen (17) clinical records reviewed. (CR#4). Findings include: Review conducted on June 8, 2023, at approximately 11 AM, of clinical records revealed: CR#4, start of care 5/26/2023, reviewed Certification Period 5/26/2023 to 7/24/2023: Physician wound care orders of 5/26/2023 (CMS 485 form) “Skilled nursing is medically necessary for skilled observation and assessment of stage 3 pressure ulcer to buttocks… Skilled nurse to observe and assess integumentary status to identify untoward changes and intervene to minimize complications."; observed wound care orders of clinical record and noted missing skilled nurse's wound measurements (dimensions for length, width, depth) documentation for present on-admission sacral/buttocks stage 3 pressure ulcers on 5/26/2023, 5/30/2023, and 6/6/2023 in the “Wound Measurement Report” and skilled nurse visit reports. Review conducted on June 8, 2028, at approximately 12 PM, of agency policy “CNAA Clinical Procedure Manual (Home Health and Home Care)” under “Key Points” details “3. Basic wound assessment for all wounds includes: … d. Dimensions: 1. Length, width, and depth … “; “5a. In home care, a professional assessment of wounds is indicated at least once a week. 5b. Reassessment and documentation of the wound should include: 1. Wound measurements … “; and under “Procedure item 6. Perform wound assessments: Assess all 10 indicators of wound status: d. Dimensions of Wound: Measure using PASIS guidance: 1. Length; 2. Width; 3. Depth … .” Interview conducted on June 8, 2023, at approximately 12:30 PM with agency administrator confirmed the above finding.

Based on the findings of an unannounced, on-site Medicare complaint investigation survey completed December 14, 2022, AccentCare Home Health of Central Pennsylvania was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts, B and C, Conditions of Participation: Home Health Agencies.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on review of medical records (MR) and interview with staff the agency failed to ensure all relevant orders were contained on the plan of care for one (1) of one (1) record reviewed. MR #1. Review of medical records completed December 14, 2022, between approximately 11:30 AM and 2:00 PM revealed: MR #1, start of care (SOC): 11/3/2022; certification period reviewed: 11/3/2022-1/1/2023; Primary Diagnosis: encounter for attention to gastrostomy, Dysphasia following cerebral infarction (difficulty swallowing after a stroke), COVID-19, Pneumonia due to coronavirus disease 2019. Physician's orders: " Skilled nursing 1 time per week for 5 weeks, 1 time every 2 weeks for 4 weeks... Skilled nurse to evaluate and develop plan of care to be countersigned by physician... ". Plan of care contained no orders regarding recent procedure to insert a pleural catheter. Medical record contained no verbal orders regarding catheter or addendums to plan of care. Interview with agency staff completed December 14, 2022, between approximately 11:00AM and 11:30 AM confirmed the above findings.

Based on the findings of an onsite unannounced home health agency Medicare complaint investigation survey conducted August 17, 2022, Accentcare Home Health of Central Pennsylvania was found not to be in compliance with the requirements of 42 CFR, part 484, Subparts Band C, Conditions of Participation: Home Health Agencies.

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 policy/procedure, medical records and interviews with staff (EMP 1 and 2) the agency failed to ensure the patient was recertified for an new certification period resulting in 2 weeks of missed nursing visits for one (1) of three (3) records reviewed. MR #3. Review of Policy HH 2.1.4 completed 8/17/22 at approximately 11:00AM revealed: Policy: " It is the policy of this Agency to begin the care planning process upon the admission of the patient to service and continue to involve the patient and /or caregiver,... through discharge". Purpose: 4. "Coordinate care through regular communication among the staff providing care, visit management and scheduling, consistent patient education, and patient incorporation in the care planning process". Procedure: 1. " The plan of care is ordered by the physician or ...and contains all pertinent diagnoses, … frequency of visits, … any other appropriate items". Review of medical records completed August 17, 2022 between approximately 10:00AM and 11:00AM revealed: MR #1, start of care (SOC): 5/27/2022, certification period: 7/26/22-9/23/22, Primary Diagnosis: Begnin Prostate Hypertrophy contained a recertification of skilled nursing visits completed on 7/21/22. MR #2, SOC: 7/21/22, certification period: 7/21/22-9/20/22, Primary diagnosis: Right Below the Knee amputation contained and initial nursing evaluation completed 7/20/22. ME#3, SOC: 3/13/22, certificaiton period: 7/10/22-9/8/22, Primary diagnosis: encounter for Orthopedic aftercare following surgical amputation contained a resumption of care completed 7/8/22 following a hospital discharge. On 7/22/22, a communication note to the patient's insurance was entered, " Need authorization for skilled nursing late recert today- patient has not been see in 2 weeks". Physicians order dated 7/22/22: "SN effective 7/10/22, 1 week 1". An interview completed 8/17/22 with EMP #1 and 2 from approximately 9:30AM until 11:30 AM confirmed the above findings.