Every finding on record at Stonerise Reliable Healthcare, LLC

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 07/20/23, Stonerise at Home is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An entrance was conducted on 07/17/23 at 9:30 AM with the Administrator. An exit conference was conducted on 07/20/23 at 4:00 PM with administrative staff. The following deficiencies are based on the partial extended recertification survey completed 07/20/23. Stonerise at Home 367442, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on medical record review policy review, observation, and interview, the agency failed to conduct a review of all medications the patient is currently taking for four of seven patients reviewed with home visits (Patient #2, #3, #6 and #7). The total sample was 17. The census was 138. Findings include: 1. On 07/17/23 a home visit was made to Patient #2 with Staff P. Patient #2 had a Start of Care (SOC) date 03/13/23. Current diagnoses included aftercare following joint replacement surgery and presence of a left artificial knee. Staff P asked the patient if there were any medication changes and Patient #2 stated "no." The medication prescription bottles were not reviewed by Staff P. Review of the medication profile for Patient #2 revealed Aspirin (ASA) 81 milligrams (mg) delayed release one tablet orally once a day and Melatonin 5 mg take one tablet at bedtime. Review of the medication bottles furnished by Patient #2’s caregiver revealed neither ASA 81 mg nor Melatonin were among them. Interview 07/17/23 at 4:10 P.M. with Patient #2’s caregiver revealed Patient #2 quit taking the ASA because she was started on Eliquis, a blood thinner. The Caregiver revealed Patient #2 was not on Melatonin when she went to the hospital. She was not given a prescription for Melatonin upon discharge. The Caregiver included Patient #2 took Zofran for nausea as needed and Ibuprofen 200 mg, two tablets twice a day as needed for pain. Interview 07/17/23 at 4:30 P.M. with Staff P verified the medication profile included Melatonin and ASA which Patient #2 was not taking. The patient also was on Zofran and ibuprofen as needed which were not included on the profile. Review of agency policy titled, “Medication Reconciliation” implemented 05/01/21, revealed the Agency will reconcile patient’s medications at time of admission and on an ongoing basis. At the time of admission, the admitting registered nurse (RN), physical therapist or speech language pathologist will create and document a complete list of medication that the patient is taking at home, including dose, route and frequency. Any discrepancies will be reconciled by a RN with the patient’s physician. Discrepancies include duplication, omissions, changes, contradictions, and/or unclear information. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. 2. On 07/18/23 a home visit was made to Patient #6 with Staff D. Patient #6 had a Start of Care (SOC) date of 02/07/19. Current diagnoses included chronic venous insufficiency and non-pressure chronic ulcer of the right calf. Staff D asked the patient if there were any medication changes and Patient #6 stated "no." The medication prescription bottles were not reviewed by Staff D. Review of the medication profile for Patient #6 included Vitamin B12 100 micrograms (mcg) orally once a day and Zyrtec 10 mg tablet take one tablet orally once a day for allergies. Review of the medication bottles furnished by Patient #6 revealed neither Vitamin B12 or Zyrtec were provided. Interview 07/18/23 at 9:10 A.M. with Patient #6 revealed he had not taken Vitamin B12 for a while. He said he did not have allergies and did not take Zyrtec. Patient #6 stated he took Acetaminophen 500 mg one or two a day as needed for pain. Acetaminophen was not included on Patient #6’s medication profile. Interview 07/18/23 at 9:16 A.M. with Staff D verified the medication profile included Vitamin B12 and Zyrtec which the patient said he was not taking. The profile did not include Acetaminophen which the patient said he took for pain. 3. On 07/18/23 a home visit was made to Patient #3 with Staff S. Patient #3 had a Start of Care (SOC) date of 07/12/23. Current diagnoses included Parkinson’s disease. Staff S asked the patient if there were any medication changes and Patient #3 stated "no." The medication prescription bottles were not reviewed by Staff S at that time. Review of the medication profile for Patient #3 revealed Vitamin D 50 mcg (2000 international units (iu) orally one tablet daily. Review of the medication bottles furnished by Patient #3’s wife revealed the Vitamin D bottle contained 25 mcg (1000 international units (iu) not 50 mcg (2000 iu). Patient #3’s wife said she was only giving one tablet. She did not realize the bottle she bought had tablets with less mcg than what was ordered. Patient #3’s wife stated when Staff G came for the initial evaluation, she gave him the list of medications. He did not look at the bottles. On 07/18/23 at 9:54 A.M. Staff S looked at the medications and verified in an interview that the Vitamin D was the incorrect strength, and two tablets should have been administered. Interview on 07/18/23 at 4:39 P.M. with Staff E revealed she expected staff to be reviewing the medications and looking at the medication bottles at each visit. If the bottles were looked at, Staff G could have instructed Patient #3’s wife on the correct dosage and number of tablets to provide her husband. 4. On 07/18/23 a home visit was made to Patient #7 with Staff G. Patient #7 had a Start of Care (SOC) date of 06/15/23. The current diagnosis was pleural effusion. Staff G looked at Patient #7’s weekly pill box and identified she had not taken a medication the previous night. He looked through her prescription bottles to identify which medication was left in the pill box. Staff did not compare what was in the weekly pill box to see if the medication in the pill box matched the medication profile. Staff G did not compare the medication profile with the handwritten list posted on the front of the refrigerator with the medications and the times taken for Patient #7. Review of the medication profile for Patient #7 revealed Senna Plus (for constipation) 50 mg-8.6 mg tablet take two tablets orally twice a day, Acetaminophen 325 mg oral tablet chewable; chew two tablets every six hours as needed, and potassium chloride 20 milliequivalents (mEq) oral tablet, extended release take one tablet orally two times a day. Observation of the prescription bottles revealed the potassium chloride was labeled 10 mEq oral tablet, take one tablet orally daily. The medications included Pantoprazole sodium EC (for gastric reflux) 40 mg one daily, a multivitamin and Senna Plus two bottles. One bottle was labeled take two as needed daily and the second bottle was labeled take one twice a day as needed. Neither were labeled take two tablets orally twice a day as written on the profile. Observation of the weekly pill box revealed there were no Senna Plus at any time of the day included. There was one multivitamin included daily in the morning, one Pantoprazole sodium EC daily and only one potassium 10 mEq daily at 9:30 A.M., which matched the prescription bottle. The profile did not contain the correct dosage and frequency of the potassium chloride, incorrectly had Senna Plus administered two tablets twice a day when they were as needed, did not include Pantoprazole sodium EC 40 mg which was added 07/11/23 and did not include the daily multivitamin. Interview on 07/18/23 at 12:10 P.M with Staff G verified the medication profile for Patient #7 was inaccurate.

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 record review and staff interview, the agency failed to ensure patients received home health services as written in the individualized plan of care for six of 17 patients reviewed (Patient #7, #8, #10, #11, #15, and #17). The census was 138. Findings include: Review of the agency’s policy titled “PC-09 Plan of Care and Physician’s Orders” effective 05/01/21, revealed if the agency provides fewer visits than the physician’s orders, it has altered the plan of care and the physician must be notified. The agency must maintain documentation in the clinical record indicating that the physician was notified and is aware of the missed visit. 1. Review of the medical record for Patient #15 and the Aide Visit Note dated 05/23/23 and 06/05/23 revealed the home health aide (HHA) called off sick and no visit was made. There was no documented evidence the physician had been notified. 2. Review of the medical record for Patient #16 and Occupational Therapy (OT) Visit Note dated 06/13/23 revealed the OT had a missed visit due to the patient refused services. There was no documented evidence the physician had been notified. 3. Review of the medical record for Patient #16 and Physical Therapy (PT) Visit Notes dated 06/22/23 and 06/27/23 revealed the PT had a missed visits due to no authorization by the insurance company. There was no documented evidence the physician had been notified. Per interview on 07/19/23 at 12:20 PM Staff E confirmed the physician had not been notified of these missed visits. 4. Review of the medical record for Patient #17 and Occupational Therapy (OT) Visit Notes dated 06/20/23 and 06/26/23 revealed the OT had missed visits due to no insurance authorization. There was no documented evidence the physician had been notified. Per interview on 07/18/23 at 4:10 PM Staff E confirmed the physician had not been notified of these missed visits. 5. Review of the medical record for Patient #10 and HHA visit sheets 06/23/23 and 07/07/23 revealed the HHA had missed visits. There was no documented evidence the physician had been notified. Per interview on 07/20/23 at 12:56 PM Staff E confirmed the physician had not been notified of these missed visits. 6. Review of the medical record for Patient #7 revealed a Start of Care (SOC) date 06/15/23. Current diagnosis included pleural effusion. Review of the medical record for Patient #7 and the Physical Therapy Assistant (PTA) visit notes dated 06/22/23 and 07/11/23 revealed the visits were missed. The 06/22/23 visit note included patient contacted the office and cancelled visit stating she was not feeling well. There was no documented evidence the physician had been notified of the missed visit. Review of the 07/11/23 missed visit note included the PTA spoke to the patient’s daughter who said the patient had a doctor’s appointment and was declining a PTA visit. There was no documented evidence the physician had been notified of the missed visit. Interview on 07/19/23 at 11:39 A.M. with Staff E verified the physician had not been notified of the PTA missed visits. 7. Review of the medical record for Patient #8 revealed a Start of Care date of 05/26/23. Diagnosis included Parkinson’s disease. Review of the aide order revealed one visit a week for four weeks. Review of the visit notes revealed there was not a visit attempted the week of 05/28/23. There was no evidence of physician notification of a missed visit. On 06/08/23 the HHA visit note included the patient did not answer the door and she knocked for 20 minutes. HHA X included she messaged the daughter with a time the previous day and messaged her when she left the home that she could not get in. There was no evidence of physician notification of a missed visit. On 06/15/23 HHA X had a missed visit. She had messaged the daughter the previous day. She said it was a good time to come. Knocked on the door for 15 minutes with no answer. Sat an hour waiting for the daughter to message her back and got not response. There was no evidence of physician notification of a missed visit. On 06/22/23 there was a HHA missed visit due to HHA X calling off. There was no evidence of physician notification of a missed visit. On 07/07/23 the Physical Therapy Assistant had a missed visit due to the patient having a doctors appointment in Pittsburgh with the Veterans Administration. There was no evidence of physician notification of a missed visit. Interview 07/19/23 at 4:33 P.M. with Staff E verified the physician had not been notified of the PTA and HHA missed visits and the deviation from the plan of care. 8. Review of the medical record for Patient #11 revealed a Start of Care date of 01/26/23. Diagnosis included Emphysema. Review of the Physical Therapy order revealed two visits a week for four weeks. Review of the visit notes revealed there was missed visit 05/30/23. The note indicated the caregiver called and did not want therapy due to the patient not feeling well. There was no evidence of physician notification of a missed visit. A missed PTA visit note 07/03/23 indicated when the PTA called the previous day to schedule an appointment. The caregiver informed the PTA he had fallen over the weekend and his hip was hurting. He was unable to do a PTA visit. She wanted to wait for the nurse to see him before she took him to the hospital. There was no evidence of physician notification of a missed visit. Interview 07/20/23 at 11:38 A.M. with Staff E verified the physician had not been notified of the PTA missed visits and the deviation from the plan of care.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure skilled professionals assumed responsibility for preparing clinical notes for one of seventeen records reviewed (Patient #8). The census was 138. Findings include: Review of Patient #8's medical record revealed a Start of Care date of 05/26/23 and orders for home health aide services (HHA) one visit a week for four weeks. Review of the visit notes revealed there was not a visit attempted the week of 05/28/23. There were missed visits on 06/08/23, 06/15/23 and 06/22/23. The first visit made by the HHA was on 06/29/23. On 06/21/23 there was a Registered Nurse 14 day supervisory visit made by Staff B. The report indicated the aide followed the plan of care, the patient was satisfied with the services, teaching had been performed, and instructions had been given related to coping strategies. Interview 07/19/23 at 4:48 P.M. with Staff E verified the aide had never made a visit to the patient and Staff B documented the aide had been providing satisfactory services and the patient was satisfied. Staff E verified a supervisory assessment for HHA care was not appropriate or accurate since the patient had not been provided HHA services.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and staff interview, the agency failed to ensure the home health aide provides services that are included in the plan of care for one of four patients reviewed that were receiving home health aide services (Patient #15). The total patient sample was 17. The census was 138. Findings include: Review of the agency policy titled, “PQ-03 Home Health Aide Services and Training Program,” effective 05/01/21, revealed the duties of the home health aide (HHA) are to provide services that are physician ordered in the plan of care and permitted to be performed by applicable state laws. Review of the medical record for Patient #15 and the aide care plan revealed the home health aide (HHA) was to provide a bath, shampoo, shave, skin care, denture care, nail care, oral care, and apply elastic stockings. Review of the Aide Visit Note dated 06/13/23 revealed the home health aide (HHA) was there from 2:00 PM to 3:03 PM and documented a COVID screening was completed and then applied personal protective equipment (PPE). The HHA documented “Patient was missing and called 911, they found him”. There was no documentation the HHA provided any personal care during the visit. The visit date and time was confirmed by the patient’s spouse with a signature on 06/13/23 at 3:05 PM. Interview on 07/19/23 at 12:26 PM with Staff E revealed the HHA was not there when the patient was missing, they were on their way to the patient’s home. Staff E confirmed the HHA did document the COVID screening, and that the family did sign the aide visit sheet. Staff E confirmed the HHA did not document that any personal care was provided to Patient #15.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and staff interview, the agency failed to ensure that if home health aide services are provided to a patient who is receiving skilled services, a registered nurse or other appropriate skilled professional made an onsite visit to the patient's home no less frequently than every 14 days for two of four patients reviewed with skilled services and home health aide services (Patient #8 and #15). The total sample was 17. The census was 138. Findings include: 2. Review of the medical record for Patient #8 revealed a Start of Care date of 05/26/23. Diagnosis included Parkinson’s disease. Review of the aide visit notes revealed the home health aide (HHA) started to provide services to Patient #8 on 06/29/23. Skilled nursing discharged 06/20/23. Review of the physical therapy visit notes reveal there were no supervisory visits made on the HHA in a 14-day period or since the HHA made her initial visit. Interview 07/19/23 at 4:33 P.M. with Staff E verified the physical therapist should have made the HHA supervisory visit by 07/13/23 and has not made the visit as of 07/19/23. Review of the agency policy titled “PQ-02 Home Health Aide Supervision” effective 05/01/21, revealed all home health aide (HHA) supervisory visits will be made at least every 14 days to assure the appropriateness of HHA services and to maintain quality of care. 1. Review of the medical record for Patient #15 and aide visit notes revealed the home health aide (HHA) started to provide services to Patient #15 on 04/27/23. Review of the registered nurse visit notes did not reveal supervisory visits were made on the HHA on 05/11/23 or 06/08/23. Per interview on 07/19/23 at 12:28 PM Staff E confirmed the HHA supervisory visits were not made every 14 days.