Managed Homecare Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop an emergency preparedness program as per the agency’s policy and procedure. This failure had the potential for the agency not to be able to respond accordingly in an emergency and could place the patients, patients’ families, and staff in danger. Findings: During an interview on July 3, 2024, at 4:09 p.m., the Operations Manager (OM) stated the Administrator (ADM) was in-charge of emergency preparedness. The OM stated the agency had an emergency preparedness policy and procedure that was reviewed by the governing body in November 2023. She stated the agency did not have an actual emergency preparedness plan in place since the change of ownership in 2022. The OM stated the facility did not participate in any community-based exercise or conducted a tabletop exercise. During a telephone interview on July 3, 2024, at 5:02 p.m., with the Registered Nurse (RN), the RN stated she had not participated in any emergency preparedness meeting conducted by the agency. The RN stated there was no drill given to her for emergency preparedness. During an interview on July 5, 2024, at 11:30 a.m., with the ADM, the ADM stated she was aware of the agency’s emergency preparedness policy and procedure but had not implemented it. The ADM stated the agency did not have a plan for emergency preparedness. The ADM stated a plan should have been developed and implemented for the agency to respond in an emergency. The facility’s policy and procedure titled, EMERGENCY MANAGEMENT PLAN,” dated January 2018, indicated, “…To establish a plan which allow for continuation of the services in the event of a disaster, natural or man-made, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records…The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations…””

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a copy of the Plan of Care (POC) and the Medication Profile were provided for one of three patients reviewed (Patient 6). This deficient practice had the potential for Patient 6 not to receive the correct medication ordered by the physician as indicated in the POC, placing Patient 6 at risk for missed treatments and/or medications, side effects for multi-drug interactions. Findings: On July 1, 2024, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with start of care (SOC) date of January 28, 2016, with diagnoses which included chronic respiratory failure (a condition when the lungs cannot get enough oxygen). Patient 6 had a current plan of care (POC) for the certification period from June 14, 2024 to August 12, 2024. Patient 6’s medication profile was dated June 6, 2024. On July 2, 2024, at 10:30 a.m., a home visit was conducted for Patient 6. Patient 6’s primary care giver (PCG) and Licensed Vocational Nurse (LVN) 3 were present during the visit. Patient 6 was observed in bed, asleep. Patient 6 had a tracheostomy (an opening surgically created through the neck to the windpipe to allow air into the lungs) and was on RA (the normal air we breathe). During a concurrent interview and record review on July 2, 2024, at 11:03 a.m., with LVN 3, LVN 3 stated she did not have a copy of the current POC and the medication profile for Patient 6. LVN 3 stated the will send her a copy of the current POC and the current medication profile. LVN 3 stated she was using a copy of the medication profile from an office visit of Patient 6 on January 2024. She stated there should have been a copy of the current POC and the medication profile in Patient 6’s folder. During an interview on July 2, 2024, at 11:35 a.m., with the patient care giver (PCG), the PCG stated the agency did not provide her with the current POC and the current medication profile for Patient 6. During a telephone interview on July 3, 2024, at 5:02 p.m., with the RN, the RN stated she submitted the current POC and the medication profile to the agency after she completed her assessment. She stated she was not sure if the agency mailed a copy of the POC and the medication profile to PCG. She stated the PCG should have a copy of the current POC and medication profile in the patient folder. During a review of the facility’s policy and procedure titled, “SAFEGUARDING/RETRIEVAL OF CLINICAL RECORDS,” dated January 2018, indicated, “...Selected documents may be kept in the patient’s home in a home clinical record while the case is active...Elements of the clinical record necessary to provide care include the plan of care...medication profile,,,” During a review of the facility’s policy and procedure titled, ‘MEDICATION PROFILE,” dated January 2018, indicated, “...The medication profile and other relevant data will be available to all clinicians providing care...””

“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 observation, interview, and record review, the agency failed to ensure the medications listed in the patient’s current plan of care (POC) and current medication profile were updated, accurate, and complete for three of three patients reviewed (Patients 1, 4, and 6). This failure had the potential for the patients not to receive the medications as ordered by the physicians, placing the patients at risk for potential side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy when: 1. For Patient 1, The medication Entresto (a medication used for heart failure that improves blood flow and reduce stress) was listed in the current medication profile as “Entresto 49-51 mg (milligram - a unit of measurement) tab (tablet) give 1/2 (one half) tab, hold if SBP (systolic blood pressure - the top number of blood pressure reading) (greater) 91% may titrate up to 3LPM to maintain O2 sat level >91% Notify MD if O2 sat level ,91% @ 3LPM O2 administration...” The agency’s document titled, “PEDIATRIC NURSING EVALUATION/MEDICAL PLAN OF CARE,” dated June 12, 2024, indicated the oxygen administration order was changed as documented by the RN. On July 2, 2024, at 10:30 a.m., a home visit was conducted for Patient 6. Patient 6’s PCG and LVN 3 were present during the visit. Patient 6 was observed in bed, asleep. Patient 6 had a tracheostomy and was on RA. a. During a concurrent interview and record review at 11:03 a.m., with LVN 3, LVN 3 stated Patient 6 had an order for RA if Patient 6’s O2 sat level is >91% and may administer O2 at 2LPM via trach as needed if O2 sat was (greater) 91% may titrate up to 3LPM to maintain O2 sat level >91% Notify MD if O2 sat level ,91% @ 3LPM O2 administration...” The agency’s document titled, “PEDIATRIC NURSING EVALUATION/MEDICAL PLAN OF CARE,” dated June 12, 2024, indicated the oxygen administration order was changed as documented by the RN. On July 2, 2024, at 10:30 a.m., a home visit was conducted for Patient 6. Patient 6’s PCG and LVN 3 were present during the visit. Patient 6 was observed in bed, asleep. Patient 6 had a tracheostomy and was on RA. a. During a concurrent interview and record review at 11:03 a.m., with LVN 3, LVN 3 stated Patient 6 had an order for RA if Patient 6’s O2 sat level is >91% and may administer O2 at 2LPM via trach as needed if O2 sat was <91%. LVN 3 stated the current POC and the current medication profile did not indicate the change in the O2 order. b. During a concurrent interview and record review at 11:03 a.m., with LVN 3, LVN 3 stated Patient 6 had an order for Multi Vitamin tablet, give 1 tablet daily via the G-tube (gastrostomy tube - a feeding tube). LVN 3 stated Multi Vitamin liquid was observed in Patient 6’s bedside. LVN 3 stated Patient 6’s PCG administered the Multi Vitamin. LVN 3 stated Patient 6’s physician should have been called to clarify the medication order. During an interview at 11:38 a.m., with the PCG, PCG stated she administered Patient 6’s Multi Vitamin liquid daily via the G-tube. The PCG stated she had been administering the Multi Vitamin liquid for several weeks. The PCG stated she was giving 15ml of the Multi Vitamin according to the instructions on the medication label. During a telephone interview on July 3, 2024, at 5:02 p.m., with the RN, the RN stated during her medication reconciliation, she would give the PCG a copy of the list of medications to check if there was a change in the medication. She stated she did not physically check the medications at the bedside to reconcile. She stated she was not aware Patient 6’s PCG was administering Multi Vitamin liquid when the order was Multi Vitamin tablet. She stated the standard of practice was to follow the physician’s order. c. During a concurrent interview and record review, at 11:03 a.m., with LVN 3, LVN 3 stated Patient 6 had an order for Tobramycin 40mg, give 2ml via nebulizer every 12 hours for 28 days on and 28 days off. LVN 3 stated the Tobramycin order did not have an indication for use. LVN 3 stated the Tobramycin order should have an indication for use. During an interview on July 3, 2024, at 11:37 a.m., with the Quality Assurance (QA) nurse, the QA nurse stated medication orders should include the name of the medication, the dose, the route of administration, the form of the medication (tablet, liquid, solution), the indication and duration for use. During a telephone interview on July 3, 2025, at 5:02 p.m., with the RN, the RN stated Patient 6’s Tobramycin order was indicated as prophylaxis for lung infections. The RN stated she was not sure why there was no indication for the use of the Tobramycin medication. She stated medication orders should have an indication for use. The RN stated the POC and the medication profile for the current certification period should reflect the changes in the medication or treatment. The facility’s policy and procedure titled, “MEDICATION PROFILE,” dated November 2018, indicated, “...Patients receiving medications will have a current, accurate medication profile in the clinical record...Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications...For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document complete list of the patient’s current medications...A comparison of the medications ordered for the patient...will be made to those on the list...The admitting nurse will initiate a medication profile to document the current medication regiment, including name, strength, dose, route, frequency, date and time of administration, and a diagnosis, condition, or indication for use for each medication ordered...” Findings: 1. On July 1, 2024, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with a start of care (SOC) date of January 22, 2024, with diagnoses which included muscular dystrophy (a condition that cause muscle weakness and muscle damage) and chronic heart failure (a condition in which the heart has trouble pumping blood through the body). The POC for the certification period from May 28, 2024 to July 26, 2024, indicated the medication was written as “Entresto 49-51 mg/tab give 1 tab via po BID (hold if SBP < 90)”. The current medication profile dated and signed by the Registered Nurse (RN) on May 28, 2024, indicated “Entresto 49-51 mg/tab give 1/2 tab (hold for SBP < 90) po BID.” The medication profile dated January 16, 2024, during the initial evaluation indicated “Entresto 49-51 mg, give 1/2 tab (hold if SBP <90) po BID.” The supplemental order dated May 7, 2024, indicated the medication Entresto 49-51 mg. was increased to one tablet twice a day by the cardiologist. The agency’s document titled, “EVALUATION/MEDICAL PLAN OF CARE,” dated May 28, 2024, indicated a medication changed as documented by the RN. On July 2, 2024, at 8:30 a.m., a home visit was conducted for Patient 1. Patient 1’s primary care giver (PCG) and the Licensed Vocational Nurse (LVN) 1 were present during the visit. Patient 1 was observed sitting up in his motorized wheelchair alert, oriented, and able to verbalized his needs. Patient 1 had a Passy-Muir Valve (PMV - a speaking valve) attached to his tracheostomy (a surgical opening into the windpipe to allow air into the lungs). During a concurrent interview and medication profile review, at 9:47 a.m., conducted with Patient 1’s PCG the PCG stated Patient 1’s medication Entresto was increased from 1/2 tablet BID to 1 tablet last May 2024, because Patient 1’s echocardiogram (a test used for heart failure) had a decline in heart function. The PCG stated she noticed that Patient 1’s SBP was bellow 90 for few nights and she held the medication. The PCG stated she called Patient 1’s cardiologist (heart specialist) on June 28, 2024, about Patient 1’s blood pressure. During a concurrent interview and medication profile review, at 10 a.m.,, with LVN 1, LVN 1 stated Patient 1 was taking the Entresto medication one tablet twice a day. LVN 1 acknowledged the current medication profile was not updated when the medication was increased from half tablet to one tablet BID. 2. On July 1, 2024, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with the SOC date of July 1, 2021, with the diagnoses which included cerebral palsy (a disorder that affect movement and coordination caused by brain damage) and seizure disorder (convulsion). The POC for the certification period from June 15, 2024 to August 13, 2024, and the current medication profile dated June 12, 2024, indicated an order for the medication Albuterol 2.5 mg/3 ml via nebulizer treatment every four hours as needed for airway clearance or increase cough/increase secretions. The nurse’s notes from June 17, 2024 to June 28, 2024, indicated the medication Albuterol was being administered by the Licensed Vocational Nurse (LVN) 2 every 8:30 a.m. On July 2, 2024, at 1:27 p.m., a home visit was conducted for Patient 4. Patient 4’s PCG and LVN 2 were present during the visit. Patient 4 was observed sitting in her stander (an assistive device for children who require more support) being cared by LVN 2. Patient 4 was non verbal, responded to the PCG and LVN 2’s verbal comment by facial gestures. bout 8:30 a.m., and she was giving the medication around 9 p.m.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician’s orders and the plan of care (POC) were signed and dated timely, within 30 days of order dates for four of eight patients reviewed (Patients 1, 2, 8, and 6). This failure resulted in verbal orders not authenticated and dated by the physicians in accordance with the agency’s policy and procedure. This failure also had the potential to result in incorrect verbally ordered medications and treatment for patients which could cause unnecessary care and services. 4. On July 1, 2024, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with SOC date of January 28, 2016, with diagnoses which included chronic respiratory failure (a condition when the lungs cannot get enough oxygen). The agency’s document titled, “COMMUNICATION NOTE/SUPPLEMENTAL ORDER(S),” dated May 6, 2024, indicated, “...Pt (patient) ok to be on RA (room air - air we normally breath) if O2 sat (oxygen saturation - percentage of oxygen in the blood) level (greater than) 91% may titrate up to 3 (three) LPM to maintain O2 sat level >91% Notify MD if O2 sat <91% @ 3LPM O2 administration..,.” The supplemental order was not signed by the physician. During an interview on July 1, 2024, at 3:37 p.m., with the OM, the OM stated the agency had a hard time getting orders signed by the physician. She stated the orders were faxed to the physician’s office multiple times for signature. The OM stated telephone or verbal orders should be signed by the physician within 30 days. During an interview on July 1, 2024, at 11:37 a.m., with LVN 2 (Anita Perez), LVN 2 stated all physician orders should be verified and signed by the physician within 30 days when the order was written. A review of the agency’s policy and procedure titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” dated January 2018, indicated “...A physician will direct the care of every home health patient admitted for service...the care will be provided in compliance with...therapeutic and diagnostic orders and accepted standard of practice...The attending physician’s verbal orders will be obtained at the time the plan of care is established. The attending physician will sign the plan of care/treatment within 30 days of the start of care, unless otherwise specified by applicable state law and regulation...” Findings: 1. On July 1, 2024, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 22, 2024, with the diagnoses which included muscular dystrophy (a condition that cause muscle weakness and muscle damage) and chronic heart failure (a condition in which the heart has trouble pumping blood through the body). - The agency’s document titled, “COMMUNICATION NOTE/ SUPPLEMENTAL ORDERS, “ dated April 29, 2024, indicated an order for “Guaifenesin 100 mg (milligram - a unit of measurement) / 5 ml (milliliter- a unit of measurement). Take 5 ml po (by mouth) q (every) 4 hours as needed for chest congestion and cough.” The supplemental order was signed and dated by the physician on June 28, 2024. The supplemental order was signed 60 days after the verbal order was written. - The agency’s document titled, “COMMUNICATION NOTE/SUPPLEMENTAL ORDERS,” dated May 7, 2024, indicated an order for “Entresto 49 mg/51 mg. Give Entresto 49 mg/51mg one tablet po twice a day (hold if SBP (systolic blood pressure - the top reading of the blood pressure) < (less than) 90.” The supplemental order was signed and dated by the physician on June 28, 2024. The supplemental order was signed 51 days after the verbal order was written. On July 1, 2024, at 3:37 p.m., a concurrent interview and record review was conducted with the Operation Manager (OM). The OM stated the supplemental orders were faxed to the physician’s office multiple times but the agency received the signed orders after 30 days. The OM stated the orders should have been signed within 30 days when the orders were written. 2. On July 1, 2024, Patient 2’s record was reviewed. Patient 2 was admitted to the agency with the Start of Care (SOC) date of November 22, 2016, with the diagnoses which included chronic respiratory failure (a condition when lungs cannot get enough oxygen into the blood), cerebral palsy (a congenital disorder of the movement, muscle tone or posture caused by brain damage). The Plan of Care (POC) for the certification period from April 14, 2024 to June 12, 2024, indicated Patient 2’s diagnoses, medications, treatments, durable medical equipment (DME), DME, supplies, hours authorized for Licensed Vocational Nurse, Registered Nurse frequency of visit, orders for discipline, goals, nutritional requirement and 60 day summary. The POC had no signature of the physician. On July 1, 2024, at 4:18 p.m., a concurrent interview and record review was conducted with the Operation Manager (OM). The OM stated Patient 2’s POC for the certification period from April 14, 2024 to June 12, 2024, was not signed by the physician. The OM stated the POC should have been signed within 30 days the POC was developed. 3. On July 5, 2024, Patient 8’s record was reviewed. Patient 8 was admitted to the agency with the Start of Care (SOC) date of October 20, 2019, with diagnoses which included Severe Intellectual Disability (a condition that affects a person’s development, behavior and the ability to learn). The POC for the certification period from May 24, 2024 to July 22, 2024, indicated Patient 8’s diagnosis, medications, treatments, supplies, orders for disciplines, authorized hours for RN and LVN for two months, goals, nutritional requirement and 60 days summary. The POC had no signature of the physician. On July 5, 2024, at 9:30 a.m., a concurrent interview and record review was conducted with the OM. The OM stated Patient 8’s POC for the certification period from May 24, 2024 to July 22, 2024, was not signed by the physician. The OM stated the POC should have been signed within 30 days when the POC was developed.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure for seven of eight skilled nurses’ files reviewed (LVN [Licensed Vocational Nurse] 2, 3, 4, 5, 6, QA [Quality Assurance] Nurse, and RN [Registered Nurse]) had received their skills and competency evaluation and annual performance evaluation according to the agency’s policy and procedure. This failure had the potential to affect the delivery of care and services to the vulnerable patients and had the potential for the skilled nurses not to be updated on the current agency’s professional standard of practices to improve their skills, performance and quality services provided to the patients. Findings: On July 5, 2024, the following Skilled Nurses’ personnel files were reviewed with the Operation Manager: - LVN 2 was hired on May 4, 2012, and was rehired on June 17, 2024. The last documented skill performance evaluation was dated May 4, 2012. There was no documented evidence LVN 2 had the competency performance evaluation completed by the agency after LVN 2 was rehired; - LVN 3 was hired on April 17, 2015. the last documented skill performance evaluation was dated April 17, 2015. There was no documented evidence LVN 3 had the current competency and annual performance evaluation by the agency; - LVN 4 was hired on April 10, 2014. The last documented skill evaluation was dated April 10, 2014. There was no documented evidence LVN 4 had the current competency and annual performance evaluation completed by the agency; - LVN 5 was hired on October 12, 2011. The last documented skill evaluation was dated October 10, 2021. There was no documented evidence LVN 5 had the current skill competency performance evaluation completed by the agency; - LVN 6 was rehired on April 3, 2021. The last documented skill evaluation was dated September 28, 2018. There was no documented evidence LVN 6 had the current competency and annual performance evaluation completed by the agency; - The QA Nurse was rehired on November 1, 2021. The last skill performance evaluation was dated July 20, 2004. There was no documented evidence the QA nurse had the current competency and annual performance evaluation by the agency; - The RN was hired on May 8, 2017. The last skill performance evaluation was dated May 19, 2017. There was no documented evidence the RN had the current competency and annual performance evaluation completed by the agency. On July 5, 2024, at 12:52 p.m., an interview was conducted with the OM. The OM stated the annual competency and annual performance evaluation for the Skilled Nurses were missed and overlooked. The OM stated the SN’s competency and annual performance evaluations should have been done annually according to the agency’s policy and procedure. The OM stated the agency had a skill evaluation checklist but was not being used. A review of the agency’s policy and procedure titled, “COMPETENCY ASSESSMENT,” dated January 2018, indicated “...Competency assessment will be completed at least one (1) time per year. Additional competencies may be required for performance issues, new technology, or other appropriate indications...” A review of the agency’s policy and procedure titled, “PERFORMANCE EVALUATION, “ dated January 2018, indicated “...All staff will be evaluated at periodic intervals based on the appropriate job description to determine strengths and areas requiring performance improvement...Triennially, based on personnel’s annual evaluation date...””