Every finding on record at Ayuda Home Health Care Services LLC

Based on record review and interview the IDT (Interdisciplinary team) in consultation with the patients attending practitioner failed to complete the comprehensive assessment within the five day window for 7 of 14 patients (Patient #1, #4, #6, #8, #11, #13 & #14) for which records were reviewed. The agency Social Worker (LMSW #2) failed to conduct an initial psychosocial assessment for these patients. Failure of the social worker to complete their part of the comprehensive assessment in a timely manner placed these patients at risk of not having their psychosocial needs met in that they would not be made aware of social services assistance that was available. The hospice social worker is responsible to conduct an initial assessment of the patient and familys acceptance of the terminal diagnosis, the presence or absence of coping mechanisms, family dynamics and communication patterns and financial resources or constraints. --- Findings Included: Review of the clinical record for Patient #1 revealed a start of care date of 05/25/2023 with a terminal diagnosis of Heart Failure. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. Review of the clinical record for Patient #4 revealed a start of care date of 10/25/2023 with a terminal diagnosis of Heart Failure. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. Review of the clinical record for Patient #6 revealed a start of care date of 03/29/2024 with a terminal diagnosis of Colon Cancer. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. Review of the clinical record for Patient #8 revealed a start of care date of 06/02/2023 with a terminal diagnosis of Alzheimers Disease. Alzheimers disease is a brain disorder that gradually destroys memory, thinking skills and eventually the ability to perform basic tasks. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. Review of the clinical record for Patient #11 revealed a start of care date of 04/25/2024 with a terminal diagnosis of Alzheimers Disease- Discharged 05/21/2024- live. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. Review of the clinical record for Patient #13 revealed a start of care date of 10/24/2023 with a terminal diagnosis of Pancreatic Cancer- Discharged 11/06/2023- due to death. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. Review of the clinical record for Patient #14 revealed a start of care date of 01/07/2024 with a terminal diagnosis of Stomach Cancer- Discharged 03/24/2024 due to death. No documentation was included that indicated an initial psychosocial assessment was conducted no later than five calendar days after admission to the agency. 10/29/2024 at 4:20 PM- Interview with DON. The clinical record for Pt #4 was reviewed. Surveyor requested to review documentation of the initial SW assessment was completed no later than five days after admission to the agency. No additional information was provided. DON stated, ";I dont know. I dont think it was done." 10/30/2024 at 12:55 PM- Interview with DON. The clinical record for Pt #11 was reviewed. Surveyor requested to review documentation of the initial psychosocial assessment was completed no later than five days after admission to the agency. No additional information was provided. 10/31/2024 at 2:35 PM- A telephone interview was conducted with LMSW #2. Surveyor asked what dates he was employed by the agency. LMSW stated 09/2021 to the end of 2023 or beginning of 2024. Surveyor reviewed the records for Pts #1, #4, #6, #8, #11, and #13 and LMSW #2 confirmed an initial SW assessment was not completed. Surveyor asked why the initial assessment was not completed no later than five days after admission to the agency. LMSW #2 stated ";The nurses told me the patients refused social worker services, so I didnt go." Surveyor asked if he attempted to contact the patients to ensure they declined social worker services and documented the service was declined. LMSW stated, ";No."

Based on record review and interviews the agency failed to ensure clinical records included documentation of physician orders for 14 of 14 records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14), updated care plans for 4 of 14 patients (Patient #2, #4, #13 and #14), missed visits and declination of SW services for 6 of 14 patients (Patient #1, #4, #6, #8, #11, #13 and #14) for which records were reviewed. Failure to ensure patient records were completely and accurately documented, organized and readily accessible, caused valuable patient information to not be available to the IDT so that they could make informed decisions regarding care and services for Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14. --- Findings included: Record review for Patient #1 revealed a start of care date of 05/25/2023. Review of the time period 07/18/2024 – 09/14/2024 revealed no documentation of physicians orders in the clinical record. Further review revealed no documentation that an initial psychosocial assessment within 5 days after admission to the agency. Record review for Patient #2 revealed a start of care date of 05/27/2022. Review of the time period 09/13/2024 – 10/29/2024 revealed no documentation of physicians orders in the clinical record. Review of the plan of care revealed no documentation of the frequencies for skilled nurse or hospice aide visits. The plan of care indicated social worker visits were ordered 1 time per month. No documentation of social worker visits or missed visits was included in record. 10/29/2024 at 3:20 PM- DON was interviewed. POC for Pt #2 was reviewed. DON acknowledged POC was incomplete in that frequency of services was not completed. SN stated they are having issues with Software- A, and sometimes things dont get added. DON stated and sometimes it gets added several times. DON stated they have contacted Software- A support but they dont always call back. Surveyor asked how staff would know how frequently they needed to provide services. SN stated, ";We talk to each other. We are a small agency, and we know all of the patients." Record review for Patient #3 revealed a start of care date of 09/13/2022. Review of the time period 09/02/2024 – 10/30/2024 revealed no documentation of physicians orders in the clinical record. Record review for Patient #4 revealed a start of care date of 10/25/2023. Review of the time period 08/20/2024 – 10/19/2024 revealed no documentation of physicians orders in the clinical record. Review of the plan of care revealed no documentation of frequencies for skilled, nurse, chaplain, and hospice aide visits. Further review revealed no documentation that an initial psychosocial assessment was completed or that the services were declined. 10/29/2024 at 4:20 PM- Interview with SN- POC for Pt #4 was reviewed. SN acknowledged frequencies were not correct and attributed the issue to Software- A. Surveyor noted there was no documentation in the clinical record of the initial SW assessment and requested any documents regarding that visit. No additional information was provided. DON stated, ";I dont know. I dont think it was done." 10/30/2024 at 9:25 AM- Interview with the Administrator and DON Surveyor discussed the findings regarding incomplete care plans and lack of M.D. orders. Administrator stated they are working to correct the problem. Record review for Patient #5 revealed a start of care date of 04/11/2022. Review of the time period 07/29/2024 – 09/26/2024 revealed no documentation of physicians orders in the clinical record. Record review for Patient #6 revealed a start of care date of 03/29/2024. Review of the time period 03/29/2024 – 05/24/2024 revealed no documentation of physicians orders in the clinical record. Further review revealed no documentation that an initial psychosocial assessment was completed or that the services were declined. Record review for Patient #7 revealed a start of care date of 07/26/2023. Review of the time period 07/20/2024 – 09/14/2024 revealed no documentation of physicians orders in the clinical record. Record review for Patient #8 revealed a start of care date of 06/02/2023. Review of the time period 07/26/2024 – 09/21/2024 revealed no documentation of physicians orders in the clinical record. Further review revealed no documentation that an initial psychosocial assessment was completed. SW frequency was 1-2 times per month + 3 prn. No documentation of SW visits or missed visits were included in the record. Record review for Patient #9 revealed a start of care date of 04/14/2024. Review of the time period 08/06/2024 – 10/04/2024 revealed no documentation of physicians orders in the clinical record. Record review for Patient #10 revealed a start of care date of 05/29/2024. Review of the time period 08/27/2024 – 10/25/2024 revealed no documentation of physicians orders in the clinical record. Record review for Patient #11 revealed a start of care date of 04/25/2024 and discharge date of 05/21/2024. Review of the time period 04/25/2024 – 05/21/2024 revealed no documentation of physicians orders in the clinical record. Further review revealed no documentation that an initial psychosocial assessment was completed or that the services were declined. 10/30/2024 at 12:55 PM- Interview with SN regarding Pt #11 initial psychosocial assessment. SN stated, ";Everything we have is in the records. We had a different social worker at that time." The name and contact information for LMSW #2 was provided. Record review for Patient #12 revealed a start of care date of 10/04/2024. Review of the time period 10/04/2024 – 10/30/2024 revealed no documentation of physicians orders in the clinical record. Record review for Patient #13 revealed a start of care date of 10/24/2023 and discharge date of 11/06/2023. Review of the time period 10/24/2023 – 11/06/2023 revealed no documentation of physicians orders in the clinical record. Review of the plan of care revealed on documentation of the frequency of skilled nurse visits. Further review of the clinical record revealed no documentation that an initial psychosocial assessment was completed or that the services were declined. Record review for Patient #14 revealed a start of care date of 01/07/2024 and discharge date of 03/24/2024. Review of the time period 01/07/2024 – 03/05/2024 revealed no documentation of physicians orders in the clinical record. Review of the plan of care revealed no documentation of frequencies for skilled nurse, hospice aide and chaplain visits. Further review revealed no documentation that social worker visits were declined or missed. 10/30/2024 at 7:03 PM- Telephone interview with RN #1. Surveyor asked who was responsible for creation of the plan of care. RN #1 stated when a patient is admitted the RN creates the plan of care. The care plans for Pt #2 and #4 were reviewed and RN #1 confirmed there were no frequencies for services included. RN stated she added the frequencies to the Software- A, but it doesnt always update. Surveyor asked how would staff know how often to provide services. RN #1 stated, ";I tell them." Surveyor reviewed the documented dates of her visits Pts #2 and #4, and she confirmed she conducted a skilled nurse visit on those dates. Surveyor asked if the agency reviews the POC during the IDT meetings. RN #1 stated ";Yes." Surveyor asked if there was any reason the lack of frequencies would not have been noted and updated. RN #1 stated, ";I dont know". 10/30/2024 at 7:20 PM- Telephone interview was conducted with LVN #1. The clinical records for Pt #2 and #4 were reviewed. Surveyor asked if she conducted visits on the documented dates (weekly). LVN #1 confirmed she completed all visits. Surveyor advised there was no frequency for SN visits in the care plan. Surveyor then asked how she determined she needed to see the patient once per week. LVN #1 stated, ";The RN tells us how often to make the visits." Surveyor asked if she reviewed the plan of care. LVN stated ";Yes". Surveyor asked if she noticed there were no SN frequencies ordered in the plan of care. LVN stated, ";No". 10/31/2024 at 9:25 AM- Interview with DON regarding the lack of written or verbal M.D. orders in the medical record for Pt #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14. SN Stated the agency has never put MD orders in the chart. The orders are all verbal and not written. They just updated the care plan and if there is a medication, then they would update the medication list. Surveyor asked how long the agency had done that. SN stated ";Always. Since we have been open. I have been the DON since it opened." 10/31/2024 at 12:25 AM- A telephone interview was conducted with LMSW #1. She confirmed she was hired in August 2024. Surveyor asked if she had visited Pt #2. LMSW stated she had not. Surveyor asked if she was aware there was an order for SW 1 time per month. LMSW stated ";No, I was not aware. To be honest I have had a lot of trouble getting access to things since I started. I just got my computer access recently." 10/31/2024 at 2:35 PM- A telephone interview was conducted with LMSW #2. Surveyor asked what dates he was employed by the agency. LMSW stated 09/2021-the end of 2023 or beginning of 2024. Surveyor reviewed the records for Pts #1, #4, #6, #8, #11, and #13 and confirmed an initial SW assessment was not completed. Surveyor asked why the initial assessment was not completed. LMSW #2 stated ";The nurses told me the pts refused social worker services, so I didnt go." Surveyor asked if he attempted to contact the patients to ensure they declined social worker services. LMSW #2 stated, ";No." Surveyor asked if he documented the reason for the missed visits. LMSW #2 stated, ";No." Review of the agencys policy titled, ";Clinical Record, JCC 013115 Hospice- CHAP" which read in part, ";The hospice must establish and maintain a clinical record system to ensure the care and services provided to each patient are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information."

Based on interview and record review, the Agency failed to update the Plan of Care to include drugs and treatments necessary to meet the needs of the patient in that 1 of 14 (Patient #11) patients Plan of Care/Medication List did not include medications Patient #11 was receiving for symptom management. This failure placed the patients at risk of a decline in their health status and could result in ineffective treatment and duplication of medications or drug interactions. --- Findings included: Review of the clinical record of Patient #11 revealed a start of care date of 04/25/2024 for a terminal diagnosis of Alzheimers disease (Progressive condition that causes a decline in memory, thinking, learning and organizational skills). Further review of the clinical record of Patient #11 revealed a Plan of Care for the certification period of 04/25/2024 to 05/21/2024. Review of the clinical record of Patient #11 revealed a skilled nursing visit note, dated 05/01/2024, documented by LVN #3, which read in part, ";...Patient is having increased pain with anxiety and SOB. Pending ABH cream (Topical medication consisting of Lorazepam (Ativan) – anxiolytic, Diphenhydramine (Benadryl) -antihistamine, and Haloperidol (Haldol) - antipsychotic) to be delivered tonight. Did give [Family member] instructions on how to apply ABH cream and also to read instruction on medication to be given as indicated to prevent anxiety episodes..." Further review of the clinical record of Patient #11 revealed a skilled nursing visit note, dated 05/20/2024, documented by LVN #3, which read in part, ";Medication change since last visit? No. Demonstrated medication compliance: Pt - Yes. Caregiver – Yes. Comments: Fentanyl (Opioid, used for pain) patch 12.5 mg." Review of the Medication Profile and Plan of Care for Patient #11 did not include the ABH cream or Fentanyl Patch. There was no evidence the Plan of Care and Medication Profile had been updated to reflect the ABH cream and Fentanyl Patch. During an interview conducted with the DON on 10/28/2024 at 12:38 PM, Surveyor reviewed the Plan of Care and Medication Profile for Patient #11 for the certification period of 04/25/2024 to 05/21/2024 with the DON. The DON confirmed the medication profile and plan of care for Patient #11 did not include the ABH cream and Fentanyl patch.

Based on record review and interview, the Agency failed to ensure the interdisciplinary group maintained responsibility for coordinating and supervising the care and services provided for 1 of 14 (Patient #11) patients whose records were reviewed, in that the Agency failed to ensure there was coordination of care with the Physician when Patient #11s Family Member contacted the Agency to report unmanaged pain and anxiety. This failure had the potential that Patient #11s needs were not met and could result in additional pain and distress for Patient #11 due to the Agencys lack of intervention for symptom management. --- Findings included: Review of the Agencys policy and procedure manual revealed a policy entitled, ";Coordination of Services," dated 01/31/2015 which read in part, ";A. The interdisciplinary group will: 1. Ensure the effective exchange and ongoing sharing of information: a. Between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement...B. The hospice Registered Nurse, or designee, will: 1. Coordinate the assessment of each patients and familys needs and implementation of the plan of care...D. Documentation of coordination of services will be filed in the Clinical Record..." Review of the clinical record of Patient #11 revealed a start of care date of 04/25/2024 for a terminal diagnosis of Alzheimers disease. Review of the Agencys On-Call Log, not dated, revealed the Agency received a call from the Family Member of Patient #11 on 05/19/2024 at 10:41 AM. The On-Call Log read in part, ";[Patient #11]...in a lot of pain and restless..." Review of the Agencys On-Call Log, not dated, revealed the Agency received an additional call from the Family Member of Patient #11 on 05/19/2024 at 3:46 PM. The On-Call Log read in part, ";CALLING AGAIN....[Patient #11]...in a lot of pain and restless." Review of the clinical record of Patient #11 failed to include a communication note regarding the phone calls received on behalf of Patient #11 regarding unmanaged symptoms on 05/19/2024 and documentation of coordination of care with the Physician regarding Patient #11s unmanaged pain and anxiety. An interview was conducted with the DON on 10/31/2024 at 1:10 PM. The on-call log was reviewed with the DON. The DON stated LVN #3 spoke with the Family Member of Patient #11 via telephone after the phone calls were received. The DON stated Patient #11s Family Members ";Refused visits a lot." The DON acknowledged there was no documentation regarding the phone calls received on 05/19/2024, on behalf of Patient #11, indicating the Physician was notified of Patient #11's unmanaged pain and anxiety.