Every finding on record at Successful Aging Inc

Based on the findings of an unannounced onsite Medicare recertification and state re-licensure survey conducted on December 11, 2023, Successful Aging, Inc., 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 Medicare recertification and state re-licensure survey conducted on December 11, 2023, Successful Aging, Inc., 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.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), and interview with the administrator and alternate administrator, it was determined that the agency failed to ensure LPN supervisory visits were documented for one (1) of one (1) clinical record (CR) reviewed (CR1). Findings Include: A review of clinical records (CR) was conducted on December 11, 2022, at approximately 9:34AM revealed: CR1, Start of Care 9/1/2023. Certification period 9/1/2023 – 11/30/2023 and 12/1/2023 – 1/29/2024. Patient diagnosed with Quadriplegia. Contained orders for Skilled Nursing (SN): Nine (9) hours per day for seven (7) days per week. Review of visit calendars on December 11, 2023 at approximately 11:20AM revealed, skilled nursing services were provided by an LPN, for the full shift of nine (9) hours per day for seven (7) days per week for September 1, 2023 through 11/30/2023, and December 1, 2023 through December 10, 2023 per physician’s orders. The surveyor requested to review the RN supervisory visit notes for the LPN. The alternate administrator stated that RN supervisory visits were conducted, however, the documentation was not available for review during the survey. An interview with the administrator and alternate administrator on December 11, 2023, at approximately 2:00PM confirmed the above findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), and interview with the administrator and alternate administrator, it was determined that the agency failed to maintain the CR in accordance with accepted professional standards for one (1) of one (1) clinical record (CR) reviewed (CR1). Findings Include: A review of clinical records (CR) was conducted on December 11, 2022, at approximately 9:34AM revealed: CR1, Start of Care 9/1/2023. Certification period 9/1/2023 – 11/30/2023 and 12/1/2023 – 1/29/2024. Patient diagnosed with Quadriplegia. Contained orders for Skilled Nursing (SN): Nine (9) hours per day for seven (7) days per week. The clinical record did not contain any documentation of clinical and progress notes by the LPN to identify the current status of the patient’s condition, or any other progress updates that were reported to the physician. An interview with the administrator and alternate administrator on December 11, 2023, at approximately 2:00PM confirmed the above findings.