Every finding on record at Adl Care at Home, Inc.

Observed in Record Review. In 1 of 2 newly admitted patient records reviewed, During RRNHV# 1's patient record review it was noted the organization had not ensured a comprehensive assessment was completed no later than five calendar days after the election of hospice care. For example: review of RRNHV# 1's RN comprehensive assessment revealed documentation that the Medical Social Worker was accepted to assist the family make a Power of Attorney change. Review of RRNHV# 1's patient record revealed a MSW initial assessment dated 20 days after the hospice election of benefit. This was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Record Review. In 1 of 4 patient records reviewed, During RRNHV# 4's patient record review it was noted the organization had not ensured it maintained accurate patient records For example: review of RRNHV# 4's RN visit notes revealed a RN visit note with documentation of a Bowel Movement (BM) dated 14 days after the date of the visit. An audit trail was requested that indicated the documentation was completed the same date of the documented last BM. This was reviewed and discussed with the Administrator that shared the BM date is a default date of the actual date the RN completes the documentation and the RN did not update the note to reflect that actual date of the last BM. This was validated with the Administrator and Director of Nursing.

Observed in Individual Tracer. In 10 of 10 patient records reviewed, The surveyor noted (RRHV#1) that the comprehensive assessment did not include an assessment and information about the patient’s psychosocial status, such as family relationships, social history, the source and adequacy of environmental and other resources, coping mechanisms, and the patient’s and family’s reactions to illness or the need for volunteer services to offer support or respite to the patient, family, or other caregivers. IT was noted that the patient declined social services. This was noted also in (RRHV#3), (RRAR#4), (RRAR#8), and (RRAR#10). There was no evidence in 10 of 10 active records that the need for volunteers was assessed.

Observed in Individual Tracer. In 5 of 17 patient records reviewed, The surveyor noted (RRHV#1) that the comprehensive assessment did not include the severity of symptoms constipation/impaction, or an diabetes assessment for a patient prescribed Jardiance and with a plan of care to monitor blood glucose levels. In (RRHV#3) there was no Diabetes assessment for patient prescribed Januvia and Glipizide on admission, also there was no assessment of the biliary catheter presented on admission. in (RRAR#5) there was no assessment of the severity of constipation/impaction, anxiety, dyspnea and in (RRAR#7) there was no assessment of the severity of constipation, agitation/anxiety. hallucinations. In (RRAR#8) there was no assessment documented of the patient PEG tube, or enteral diet as the patient was NPO. This was confirmed with the administrator.

Observed in Individual Tracer. In 4 of 17 patient records reviewed, The surveyor noted (RRHV#2) that there was no RN assessment update, completed at least every 15 days for several periods. There was no evidence that the RN assessed the patient from the end of August until the end of October (54 days) The beginning of November to the beginning of December (28 days), the middle of December to the beginning of January (32 days) and the beginning of February to the middle of March (43 days). In (RRAR#4) there was no RN assessment for 30 days April-May, and 25 days from May to June. In (RRAR#5) there were no RN assessments for (35 days) in February-March 30 days November to December and (30 days) December to January. In (RRAR#7) there was no RN assessment for (25 days) in March and (20 days) April to May. The surveyor was informed by the administrator that the notes had nor been submitted by the nurses to the EMR, but the visits were performed and that the documentation was submitted on the last day of survey. This could not be audited or validated on site.

Observed in Individual Tracer. In 17 of 17 patient records reviewed, The surveyor noted that (RRHV#1) the plan of care did not include time frames for achieving outcomes. For example, the initial plan of care included a goal for blood sugar less that 200; however it did not specify when the goal was to be achieved. Also, the patient had a Foley catheter inserted in June and there was no plan of care update for managing the Foley or goals and measurable outcomes of care. In (RRHV#2) there was no care plan to address the COVD diagnosis only cough due to COVID. In 10/17 records there were no measurable outcomes and in 17/of 17 records there were no timeframes for achieving outcomes.

Observed in Individual Tracer. In 2 of 17 patient records reviewed, The surveyor noted that in (RRHV#2) the oxygen order was not updated. The original order was O2 4lpm NC continuous; however the patient was receiving O2 at 2-3LPM since February. In (RRHV#3) the oxygen order was incomplete and did not include a frequency. In (RRAR#9) the IV order was incomplete and did not include a rate of infusion for Hydromorphone 1 mg/ 0.5 ml IV stat then Q 12 hours prn for severe pain. Also, the patient was receiving intravenous Normal Saline for hydration; however, there was no plan of care established for managing the infusion or dehydration. There was no written order to perform an IV peripheral insertion as documented completed in May. It was confirmed with the director.

Observed in Individual Tracer. In 1 of 17 patient records reviewed, The surveyor noted (RRHV#1) that there was no information on the IDG meeting notes or the comprehensive assessment to reflect the patient progress toward established goals since the patient was admitted including blood glucose management, constipation management and safety risk. Also, the plan of care was not revised to include goals and intervention for managing the patient's Foley catheter since it was inserted in June.

Observed in Individual Tracer. In 1 of 17 patient records reviewed, The surveyor noted (RRHV#3) that the patient was measuring and recording his blood sugars. The plan of care indicated that the blood glucose parameter was less than 200. The visit notes from May did not include any information about the blood glucose levels. The surveyor noted that the patient had kept a record of his blood glucose levels in his home. He had recorded levels above 200 for several days in May including one mid MAY at 359. There was no indication that the hospice had reported the increased levels to the physician. Also, there was no indication that a level of 276 in mid June was reported. At the end of June the visit note indicated that the levels were ranging from 160-260; however, there was no evidence of communication with the physician. This was confirmed with the administrator.

Observed in Individual Tracer. In 5 of 10 patient records reviewed, The surveyor noted that the patient declined a spiritual/chaplain services and the nurse was left to assess spiritual needs. In (RRHV#1) the comprehensive assessment did not include a patient and family spiritual orientation, including their desire for the involvement of a religious group. This was also noted in (RRHV#3), (RRAR#4), (RRAR#7), and (RRAR#10) and confirmed with the administrator.

Observed in HR File Review. In 4 of 7 HR files reviewed, The surveyor noted that there was no evidence in the personnel file of HR#5, HR#6 and HR#7 that a competency assessment had been completed on hire or since. Also, the competency for HR##2 had not been completed for the past three years. This was confirmed with the administrator.

Observed in Individual Tracer. In 1 of 3 HHA patient records reviewed, The surveyor noted (RRHV#2) that a registered nurse aide supervision was not completed every 14 days for several periods. There was no RN supervision completed for from the end of August until the end of October (54 days) The beginning of November to the beginning of December (28 days), the middle of December to the beginning of January (32 days) and the beginning of February to the middle of March (43 days). This was confirmed with the administrator. The surveyor was informed that the visit notes had not been submitted; how this could not be audited and validated on site.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level deficiency at 484.54 and 414.100.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The surveyor noted (RRHV#1) that a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services was not complete after the medication reconciliation was completed. The surveyor noted that Imodium was at patient's bedside and it was confirmed by sister to be active medication. This was corrected on site and confirmed with the director of nursing.

Observed in Individual Tracer. In 14 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the two physician signatures on the Do Not Resuscitate form were not dated. Also, the physician signature on the IDG meeting notes since the patient admission were not dated in (RRHV#2). The surveyor noted in 17/17 records that the physician failed to date all signatures on the IDG notes . Also the date for the MD signature on the DNR forms in (RRHV#2, (RRHV#3) (RRAR#5) and (RRAR#9) did not have a date for the physician signatures on the Do Not Resuscitate forms. The date space was left blank. This was confirmed with the administrator.

Observed in Individual Tracer. In 2 of 17 patient records reviewed, The surveyor noted (RRHV#2) that the hospice failed to provide education and training to the primary caregiver as appropriate to the responsibilities assigned to the caregiver in the plan of care. The patient developed a wound in August and the September plan of care included orders for wound care every other day. /the nurse was only visiting 1-2 x a week and there was no indication that the caregiver received education and training for performing the wound care. The surveyor noted (RRHV#3) that the assessment indicated that the patient had a biliary drainage bag; however, there was no documentation to confirm that the patient/caregiver was educated on the management of the drain and was able to manage the care. This was confirmed with the director.

Observed in Building Tour. The Class K fire extinguisher in the kitchen was mounted to the wall with the top of the extinguisher 69-inches above the floor. This was verified by the Administrator. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. An open 2-inch cable sleeve that penetrated the smoke barrier wall above the ceiling in the corridor by the Magnolia room was NOT sealed. This was verified by the Administrator. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The 90-minute fire rated door pair in the main lobby by the kitchen did NOT have approved FIRE EXIT HARDWARE as required by NFPA 101- 2012, 7.2.1.7.2. This door pair was equipped with panic hardware with a dog-down feature to retract the latch and thus disable the door's positive latch function. One of the door leaves was observed dogged down and thus did NOT latch when tested. This was verified by the Administrator. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. The 90-minute fire rated door to the biohazardous waste room did NOT close and latch when tested. This was verified by the Administrator. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Document Review. The Annual Fire Alarm Inspection and Test documentation for 2024 and 2023 was a test acknowledgement that did NOT include the following: an INVENTORY of initiating devices (smoke, heat, and duct detector; and manual pull stations) and notification appliances (speakers, horns, chimes, and strobes), the RESULTS of the activity (other than System Normal), and the NFPA REFERENCE for the activity. This was verified by the Administrator. Observed in Building Tour. The SOURCE valve for the medical vacuum system in the Basement, and the medical air manifold on the 1st floor, was NOT labeled to indicate the valve type (source), name of medical gas, area(s) served, and a caution not to close except in an emergency, as required by NFPA 99-2012, 5.1.4.4.2 and 5.1.11.2. This was verified by the Administrator. Observed in Building Tour. The electrical outlet within 2 feet of the sink in the medication room was NOT a ground-fault circuit interrupter (GFCI) protected circuit. This was verified by the Administrator.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure that pain assessments included criteria that was consistent with the patient's condition. For example, a review of the medical record for HosSSHV#1 revealed that, during week 3 of services the clinician documented the presence of back pain and a new order for Tramadol 50mg every 4 - 6 hours as needed. The pain assessment did not include quality, patterns of radiation, and character; Alleviating and aggravating factors; Pain management history, including medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain; Effects of pain, these include impact on daily life, function, sleep, appetite, relationships with others, emotions, and concentration. Secondary symptoms related to pain, such as nausea, vomiting, respiratory distress, or nutritional compromise. Example #2: A review of the medical record for HosSSRR#2 revealed that, during week 11 of the 1st benefit period the clinician documented that the patient complained of pain at bilateral lower extremities unrelieved by Tylenol. A new order for Tramadol 50mg every 4-6 hours as needed was obtained. There was no documented evidence that a pain assessment that included the following information was completed: [intensity, quality, patterns of radiation, and character; Alleviating and aggravating factors; Pain management history, including medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain; Effects of pain, these include impact on daily life, function, sleep, appetite, relationships with others, emotions, and concentration. Secondary symptoms related to pain, such as nausea, vomiting, respiratory distress, or nutritional compromise]. This observation was reviewed with the Administrator.

Observed in Record Review. There were no measurable outcomes or target time frames to accomplish and measure goals as required by regulation. This was discussed with the Administrator. HOSphRR#1, HOSphHV#1, HOSphHV#2, HOSphRR#2

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required elements. For example, a review of the medical record for HosSSHV#2, revealed that during the 6th benefit period, the patient developed 2 small ulcers to her left lower extremity and the goal statement was Wound management. The plan of care did not include a measurable goal statement related to the wound problem and/or a method to determine the effectiveness of implemented interventions. Example #2: A review of the medical record for HosSSHV#3, revealed that during week 5 of the first benefit period the clinician documented the presence of a wound at the right buttocks. The goal statement was Wound heal. The plan of care did not include a measurable goal statement related to the wound problem and/or a method to determine the effectiveness of implemented interventions. This observation was reviewed with the Administrator

Observed in Patient Home. In 2 of 2 home visits conducted with the registered nurse, he failed to follow agency policy related to hand hygiene. For example, in both patient rooms he dropped equipment (thermometer, BP cuff), picked it up off the floor, went to his bag to get a cleaning cloth,and did not change his gloves; there were multiple times he entered his clinical bag without removing gloves or performing hand hygiene; and he examined the patient's feet, then moved up to a wound on the knee, peeled back the dressing, replaced the dressing and then moved up to the patient's right arm to examine a bruise all without changing his gloves (home visit #1). This was discussed with the Administrator.

Observed in Record Review. In review of record HOSphRR#1, the documentation was inaccurate and incomplete. For example in the admission assessment the nurse documented that the patient had no wounds but orders existed for care to the patient's decubitus wound. One of the admitting diagnoses for this patient was uncontrolled pain but the admitting nurse documented no pain in the admitting assessment. This was discussed with the administrator.

Observed in Document Review. The organization did not ensure that information related to the management and disposal of controlled medications was present in the admission packet, patient handbook or documents provided to patient and family. This observation was reviewed with Administrator.

Observed in Building Tour. The organization did not ensure that state law was followed related to controlled drugs listed in Schedules II, III, IV, and V being stored in locked compartments within a secure storage area. For example, during a tour of the inpatient unit, it was noted that morphine sulfate was not stored in a locked compartment in the medication room. This observation was reviewed with the Administrator. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.

Observed in Building Tour. The surveyor observed that the piping for approved automatic sprinkler systems was supporting other items. For example, there were 2 silver coiled conduits resting on the sprinkler pipe. This observation was reviewed with the Administrator. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Record Review. For 2 of 2 patients who resided in a nursing facility, there was no documentation in clinical records that the hospice plan of care had been developed with the facility and identified which provider of care would perform which tasks as required by regulation. This was discussed with the Administrator. (HOSphHV#1 & #2)