Every finding on record at A*Med Health, LLC

Based on record review and interview, the agency administrator failed to govern the day to day operations in the agency to ensure that in-patient respite care was provided in a participating Medicare or Medicaid facility for 1 of 3 patients (#1) who received in-patient respite care. The agency coordinated the admission of patient #1 into a non-participating Medicare or Medicaid certified facility for respite care from 6-7-21 to 6-13-21. Failure of the administrator to ensure that patients are provided in-patient respite care services by a participating Medicare or Medicaid facility could affect any patient seeking respite. This deficient practice could result in patients being provided care and services by a non-participating Medicare or Medicaid facility who did not have established patient care policies consistent with those of the hospice. The findings included: Record review of complaint #345886 read in part " ... the client was placed on respite care at [ facility #1] from 6-7-21 to 6-13-21 ..." Review of the agency's contract for in-patient services with facility #1 dated 5-2-20 read in part,"...the facility is certified to participate in the Medicare program ...facility also represents that it is certified to participate in the Medicare and Medicaid programs ...Facility shall provide to Hospice Patients Hospice Inpatient Services, including but not limited to treatment, medications, emergency services, nursing services, dietary, housekeeping . and ancillary services ...All services will be provided in accordance with Medicare requirements and accepted standards." Record review of the state TULIP system revealed that facility #1 is an assisted living facility, There was no evidence in TULIP that facility #1 was in the Medicare program. During an interview on 5-24-22 at 2:20 pm the administrator/supervising nurse was made aware that facility #1 was not certified in the Medicare program. When asked how the agency ensured that patient #1 got the care required if facility #1 was not Medicare certified. The administrator/supervising nurse stated" [ facility #1] signed the Medicare thing [contract] ...other than the daily visit by the nurse, the nurse would visit daily, and the facility would call with any issues or concerns." Further interview with the administrator/supervising nurse revealed that the social worker is the person responsible for verifying that facilities are qualified to care for hospice patients. Review of patient #1's clinical record revealed a SOC date of 3-7-20 and a terminal diagnosis of other specified degenerative diseases of nervous system. Record review of IDG summary dated 5-26-21 and 6-9-21 documented the frequency of skilled nurse visit was one to three times a week for nine weeks. Further review of the clinical record revealed that patient #1 started respite at facility #1 on 6-7-21 due to family member needing time to complete projects in the home. Record review of skilled nursing notes between 6-7-21 and 6-13-21 revealed skilled nursing visits were done on 6-10-21, 6-12-21 and 6-13-21. Further review of the clinical record revealed that there was no evidence that nursing visits were ordered daily while patient #1 was at facility #1. Record review of coordination notes completed by social worker B and co-signed by social worker A dated: 4-5-21 documented " ...called wife of patient and she said she is going to wait until May or June to use respite. I told her to just let us know a week before needing ..." 5-13-21 documented "Social worker called [family member] of patient to check on respite care. She is wanting to send [patient #1] to [facility #1] on June 7th for a week ..." 5-14-21 documented "I had visited [facility #1] and I had asked about respite for [patient #1] ...[family member] is not exact on days she would like to use she is still deciding ...she will call a week in advance." 6-2-21 documented "[social worker B] received call from spouse of patient. She is taking respite at [facility #1] on the 7th of June thru return on the 14th ...I will set up transport and DME closer to the weekend ..." Record review of psychosocial prn visit dated 6-9-21 documented patient is at [facility #1] on 5 days respite and 2 days the [family member] is private paying . [Patient #1] is a total care (caregiver) needed time to complete projects in the home. Patient was asleep during visit. [Patient #1] appeared comfortable and dresses appropriately. No concerns from staff or family." During an interview on 5-24-22 at 3:16 pm Social Worker A stated "We have a general understanding as the social work team that patients need to be in 24 hour nursing facilities [for respite]. I am not sure why that arrangement was made [ with facility #1]. I am aware that I signed [ social worker B] notes as the LMSW. I am not familiar with that facility [facility #1] to know it was not a Medicare facility. Traditionally we do have patients in AL facilities [providing Hospice services], I'm not sure [about this facility] because traditionally we place them at Medicare certified facilities." Review of the agency's policy titled "Levels of Care " revised on 10-1-19 read in part, "...Inpatient respite is provided by arrangement through a written agreement to patients whose care is covered under Medicare or Medicaid Hospice benefit or specific private insurance hospice benefits ... The agency will maintain a method of verifying the requirements in the written agreement with the facility are met...It can be provided in a hospital, hospice facility, or a long term care facility that has sufficient 24 hour nursing personnel present on all shifts to guarantee that the patient's needs are met in accordance with the Plan of Care ..."

Based on record review and interview, the agency failed to ensure that in-patient respite care was provided in a participating Medicare or Medicaid facility for 1 of 3 patients (#1) who received in-patient respite care. The agency coordinated the admission of patient #1 into a non-participating Medicare or Medicaid certified facility for respite care from 6-7-21 to 6-13-21. Failure of the agency to ensure that patients are provided in-patient respite care services by a participating Medicare or Medicaid facility could affect any patient seeking respite. This deficient practice could result in patients being provided care and services by a non-participating Medicare or Medicaid facility who did not have established patient care policies consistent with those of the hospice. The findings included: Record review of complaint #345886 read in part " ... the client was placed on respite care at [ facility #1] from 6-7-21 to 6-13-21 ..." Review of the agency's contract for in-patient services with facility #1 dated 5-2-20 read in part,"...the facility is certified to participate in the Medicare program ...facility also represents that it is certified to participate in the Medicare and Medicaid programs ...Facility shall provide to Hospice Patients Hospice Inpatient Services, including but not limited to treatment, medications, emergency services, nursing services, dietary, housekeeping . and ancillary services ...All services will be provided in accordance with Medicare requirements and accepted standards." Record review of the state TULIP system revealed that facility #1 is an assisted living facility, There was no evidence in TULIP that facility #1 was in the Medicare program. During an interview on 5-24-22 at 2:20 pm the administrator/supervising nurse was made aware that facility #1 was not certified in the Medicare program. When asked how the agency ensured that patient #1 got the care required if facility #1 was not Medicare certified. The administrator/supervising nurse stated" [ facility #1] signed the Medicare thing [contract] ...other than the daily visit by the nurse, the nurse would visit daily, and the facility would call with any issues or concerns." Further interview with the administrator/supervising nurse revealed that the social worker is the person responsible for verifying that facilities are qualified to care for hospice patients. Review of patient #1's clinical record revealed a SOC date of 3-7-20 and a terminal diagnosis of other specified degenerative diseases of nervous system. Record review of IDG summary dated 5-26-21 and 6-9-21 documented the frequency of skilled nurse visit was one to three times a week for nine weeks. Further review of the clinical record revealed that patient #1 started respite at facility #1 on 6-7-21 due to family member needing time to complete projects in the home. Record review of skilled nursing notes between 6-7-21 and 6-13-21 revealed skilled nursing visits were done on 6-10-21, 6-12-21 and 6-13-21. Further review of the clinical record revealed that there was no evidence that nursing visits were ordered daily while patient #1 was at facility #1. Record review of coordination notes completed by social worker B and co-signed by social worker A dated: 4-5-21 documented " ...called wife of patient and she said she is going to wait until May or June to use respite. I told her to just let us know a week before needing ..." 5-13-21 documented "Social worker called [family member] of patient to check on respite care. She is wanting to send [patient #1] to [facility #1] on June 7th for a week ..." 5-14-21 documented "I had visited [facility #1] and I had asked about respite for [patient #1] ...[family member] is not exact on days she would like to use she is still deciding ...she will call a week in advance." 6-2-21 documented "[social worker B] received call from spouse of patient. She is taking respite at [facility #1] on the 7th of June thru return on the 14th ...I will set up transport and DME closer to the weekend ..." Record review of psychosocial prn visit dated 6-9-21 documented patient is at [facility #1] on 5 days respite and 2 days the [family member] is private paying . [Patient #1] is a total care (caregiver) needed time to complete projects in the home. Patient was asleep during visit. [Patient #1] appeared comfortable and dresses appropriately. No concerns from staff or family." During an interview on 5-24-22 at 3:16 pm Social Worker A stated "We have a general understanding as the social work team that patients need to be in 24 hour nursing facilities [for respite]. I am not sure why that arrangement was made [ with facility #1]. I am aware that I signed [ social worker B] notes as the LMSW. I am not familiar with that facility [facility #1] to know it was not a Medicare facility. Traditionally we do have patients in AL facilities [providing Hospice services], I'm not sure [about this facility] because traditionally we place them at Medicare certified facilities." Review of the agency's policy titled "Levels of Care " revised on 10-1-19 read in part, "...Inpatient respite is provided by arrangement through a written agreement to patients whose care is covered under Medicare or Medicaid Hospice benefit or specific private insurance hospice benefits ... The agency will maintain a method of verifying the requirements in the written agreement with the facility are met...It can be provided in a hospital, hospice facility, or a long term care facility that has sufficient 24 hour nursing personnel present on all shifts to guarantee that the patient's needs are met in accordance with the Plan of Care ..."

Based on record review and interview, the hospice supervising nurse or the alternate supervising nurse did not ensure that the complete nursing needs 1 of 1 Patient (#1) were met in that the Registered nurse failed to conduct a home visit and provide nursing services as outlined in the plan of care which resulted in the client's worsening change in condition. This failure resulted in Patient #1 not receiving adequate care while under the care of the agency and being discharged home without nursing care or services. This failure puts all agency patients at risk of deteriorating health status. The findings included: The record review of the Patient #1's CR revealed an admission date of 03/17/2022 with an initial PoC that included a benefit period 03/17/2022 through 03/30/2022 The record review of Patient #1's PoC revealed: - Terminal Diagnosis of Malignant Neoplasm of Larynx unspecified; other diagnoses include COPD - Order for treatment included SN visits: 1 to 3 times a week for 13 weeks; MSW: 1 visit every other week for 2 weeks and SC: 1 visit every other week for 2 weeks The record review of the Patient #1's initial assessment revealed: - The Patient lived alone, inside a trailer home "during the day" - Patient # 1 had Tracheostomy - Patient #1 had abnormal diminished breath sound due to underlying disease process and other commodities - Patient #1 "is not always able to cook and/or feed self and has no caregiver assist ..." - Patient #1 "had suicide attempt per Client#1's friend ..." The record review of the "Clinical Evaluation/LCD Visit" note revealed [Identifier 100] was indicated as the primary Caregiver. The record review of the Care Coordination note made by Supervising Nurse read in part; " ...This patient has refused the nurses access to visit him. Today is the 14th day without an RN visit. Staff was instructed to let the patient know he will be discharged unless he allows for RN to visit ...pt did not answer the phone as he requested for staff to call him first before visiting ...." Further record review of agency's CR revealed: - There was no record that the agency's made an effort to reach out to Patient #1's second "Authorized person of contact" [Identifier 200] when the agency's clinician could not reach Client#1 by phone. - There was no record of home visit made by [RN-B] to check on Patient #1 when [RN-B] was unable to reach Patient #1 by phone. - The record review of Patient #1's CR revealed an initial assessment dated 03/17/2022, however, there was no record that the [RN-B] visited Patient #1 following the initial assessment visit. - There was no record of evidence that the agency made a reasonable effort to resolve Patient #1's care issues and challenges before discharging Patient #1 for cause. Furthermore, there was no record of evidence to show that Patient #1's unanswered phone call equates refusal of nursing care. The record review of Patient #1's face sheet revealed Primary contact [Identifier 100] and Second contact [Identifier 200] as "Authorized Contacts" The record review of "Missed Visit" note dated 03/18/2022, and electronically signed by [RN - B] on 03/21/2022 read in part "call patient no answer." The record review of "Missed Visit" note dated 03/25/2022, and electronically signed by [RN - B] on 04/07/2022 reads in part "Patient/Caregiver Declined ... after several attempts to see patient, unable to schedule SN visits" Record review of Care Coordination note dated 03/21/2022 read in part " ...Received call from social worker regarding patient request for SN, SNV schedule, per patient request for SN to call him before visit and leave him text msg. and would return call. SN call patient left msg. via text as director, patient yet to return call to SN. this end of the day 05:00 PM ..." Record review of Care Coordination note dated 03/21/2022 reads in part " ...SW called [Identifier 200] and she said the patient left and she does not know where he is ...." The record review of "unattended Discharge Note" read in part; " ...Patient was admitted to hospice care. Unable to reach patient to perform skilled nurse visit ..." Further review of the discharge record revealed Client#1 was "discharged for cause ..." The presurvey review of the intake information on the HHSC - TULIP web-based system read in part "IT TOOK THE HOSPICE AGENCY THREE DAYS TO COME OUT AND DO THEIR INITIAL ASSESSMENT. THE NEXT DAY, AFTER HE WAS ASSESSED, ... THE HOSPICE AGENCY NEVER RETURNED ACCORDING TO THE [Identifier 200]. [Identifier 200] CALLED THE AGENCY SEVERAL TIMES AND WAS TOLD SOMEONE WOULD BE OUT. STAFF NEVER CAME OUT TO CHECK OR CLEAN HIS TRACHEOSTOMY. THE CLIENT NOW HAS AN ABSCESS IN THE BACK OF HIS THROAT AS A RESULT... " In an interview with [Identifier 200] on 04/07/2022 at approximately 02:15pm, she stated that Patient #1 lived alone inside a trailer home with no family member or relatives. She added that she had always been the one to assist Patient #1 with his caregiving needs. She stated that she called the agency several times after the initial assessment was completed but none of the agency representatives called her back. She also stated that she called several times to inform the agency that no clinician had showed up to care for Patient #1 and that Patient #1's condition was worsening, however none of the agency representatives or clinicians visited Patient #1 afterwards. She added that the only time she received a call was when the agency called her to inform her that the Patient #1 was discharged, and that the agency needed to pick up its medical equipment it provided to Patient #1 during admission. [Identifier 200] also stated that she had informed the agency representatives at the time of admission to always call her if the agency was unable to reach Patient #1 and that the agency was aware Patient #1 did not like to respond to phone calls due to his tracheostomy that impeded his ability to speak clearly. She added that " ...the agency knows when to call me when they want to pick up their medical equipment ....but they couldn't call me when they were trying to reach [ Patient #1] ..." [Identifier 200] also denied that she told the SW that "she said the patient left and she does not know where he is ..." In an interview with [SW-C] on 04/08/2022 at approximately 11:30 AM, [SW-C] stated that she had spoken on the phone with Client#1, and that Client#1 did not want social worker to visit him, and that Client#1 had no family member or relatives who could care for Client#1 In an interview with [RN-A] on 04/08/2022 at approximately 10:40 AM, stated that she was only responsible for admission assessment of Client#1, and that she had called Client#1's phone number but could not reach Clien#1, and that she however conducted a home visit, met with Client#1 and was able to conduct the initial assessment. She stated she could not provide the surveyor with further explanation as to why further skilled nursing visits were not made as written in the plan of care. In an interview with the Supervising Nurse and telephone interview with [RN-B] on 04/08/2022 at approximately 12:30 PM, the above findings were presented, [RN-B] stated that Client#1 asked to text him prior to home visit; she also stated that she attempted phone call twice and sent a text to Client#1 but could not reach Client#1, and that was the reason she did not conduct home visit. [RN-B] added that she would not want to visit Client#1 because " ...she will be violating Client#1's rights ..." Supervising nurse added that the agency could not contact [Identifier 200] because Client#1 did not have MPOA on file, and [Identifier 200] was not the MPOA. No further supporting evidence was provided to the surveyor at the time of the survey.