Aspire Home Healthcare

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to complete visit frequency order per the Plan of Care (POC) for three of 17 sampled patients (2, 10, 11). As a result, patients did not receive their needed care and services. 2. Per the Home Health Certification and Plan of Care, dated 8/27/24 through 10/25/24, Patient 10 was admitted to the agency on 6/28/24 with diagnoses that included a pressure ulcer (wound) to the sacral area (bottom of the spine). A review of Patient 10’s clinical record was conducted. Per the POC, Patient 10 was to be seen by the Certified Home Health Aide (CHHA) twice a week. The week of 10/15/24 through 10/21/24, the CHHA visited Patient 10 once a week instead of two. 3. Per the Home Health Certification and Plan of Care, dated 8/28/24 through 10/26/24, Patient 11 was admitted to the agency on 7/5/23 with diagnoses that included a pressure ulcer (wound) to the left buttock. A review of Patient 11’s clinical record was conducted. Per the POC, Patient 11 was to be seen by the Skilled Nurse (SN) once a week. The week of 9/8/24 through 9/14/24, no SN visit was made to Patient 11. On 11/22/24 at 10:42 A.M., a telephone interview and record review was conducted with the Regional Director of Nursing (RDON). The RDON stated visit frequency for Patient 10 and Patient 11 were missed. Per the agency’s policy, titled Missed Visit, dated 11/28/08, “...Documentation of the missed visit will be entered into the medical record....” Findings: 1. Per the Home Health Certification and Plan of Care (POC), dated 11/13/24 through 1/11/25, Patient 2 was admitted to the agency on 11/13/24 with diagnoses that included surgical aftercare (treatment to recover from surgery), and directed the Physical Therapist (PT) to visit Patient 2 one time per week for four weeks. A review of Patient 2’s clinical record was conducted. On the week of 11/10/24 through 11/16/24 there were no documented PT visits. On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, Patient 2’s PT visit frequency should have been ordered to start later. The RDON further stated, the PT visit frequency was started too early, which resulted in a missed visit.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interviews and record review, the agency failed to ensure a patient clinical record was accurate for one of 17 sampled patients (9). This failure resulted in inaccurate clinical records that could affect Patient 9’s plan of care. Findings: Per the Home Health Certification and Plan of Care (POC), dated 10/22/24 through 12/20/24, Patient 9 was admitted to the agency on 10/22/24 with diagnoses that included Parkinson’s Disease (a brain disorder that affects movement and other parts of the body). A review of Patient 9’s clinical record was conducted. Per the PTA (Physical Therapy Assistant) Visit Note, the following entries were documented by PTA 3: On 10/24/24, PTA 3 documented Patient 9 stated, “He (Patient 9) fell yesterday...” On 10/31/24, PTA 3 documented Patient 9 stated, “He (Patient 9) fell yesterday...” On 11/5/24, PTA 3 documented Patient 9 stated, “He (Patient 9) fell yesterday...” On 11/7/24, PTA 3 documented Patient 9 stated, “He (Patient 9) fell yesterday...” On 11/21/24 at 8:10 A.M., an interview was conducted with Patient 9. Patient 9 stated he fell twice while under the care of the agency, which was the beginning of service and today [11/21/24]. On 11/22/24 at 8:29 A.M., an interview was conducted with PTA 3. PTA 3 stated their computer system allowed them to copy and forward their previous note to the current home visit. PTA 3 further stated it was an error in his documentation, and Patient 9 had one fall from 10/24/24 through 11/7/24. On 11/22/24 at 11:03 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated the clinician should document the patient’s condition accurately. The agency could not provide policies and procedures for the accuracy of the clinical records.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, the agency failed to document all resolutions on the complaint log for two of nine sampled complaints. As a result, the complaints may not have been resolved. Findings: On 11/21/24 a review was conducted of the agency’s undated Complaint Log. On 1/21/22 there was a complaint that a patient had been on service since 1/8/22 (13 days), and had not yet been seen by the physical therapist. There was no documentation of the agency’s response to the complaint. On 1/24/22 there was a complaint that the agency had not provided any visits to the patient in the two weeks they had been on service. There was no documentation of the agency’s response to the complaint. On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, he responded to the patient’s complaints, but did not document his response on the Complaint Log. Per the agency’s undated policy on complaints, titled Standard HH2-4A, “…A record of the complaint, investigation, follow-up action, outcome and response to the patient/family/caregiver is documented…””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to admit a patient within 48 hours of the referral for two of 17 sampled patients (2, 12). As a result, patients had a delay in care and services. Findings: 1. Per the Home Health Certification and Plan of Care, dated 11/13/24 through 1/11/25, Patient 2 was admitted to the agency on 11/13/24 with diagnoses that included surgical aftercare (treatment to recover from surgery). A review of Patient 2’s clinical record was conducted. Per the referral, dated 11/6/24, Patient 2 was referred to the agency, and on 11/6/24 the agency responded, “…Yes, willing to accept patient…” On 11/22/24 at 8:30 A.M., an interview was conducted with the Scheduler. The Scheduler stated, she received the referral for Patient 2 on 11/8/24, and she did not know why he was not admitted until 11/13/24. 2. Per the Home Health Certification and Plan of Care, dated 11/12/24 through 1/10/25, Patient 12 was admitted to the agency on 11/12/24 with diagnoses that included a fracture of the right lower leg (broken bone). A review of Patient 12’s clinical record was conducted. Per the Printable Review Referral, dated 11/6/24, Patient 12 was referred to the agency. On 11/23/24 at 9:42 A.M., an interview was conducted with the Scheduler, and she stated she was not sure why the initial visit did not happen timely. The agency’s undated referral policy, titled Standard HH5-13A.01, did not direct staff to admit new patients within 48 hours of the referral.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to complete all evaluations within five days of the start of care for three of 17 sampled patients (1, 2, 8). As a result, the patient’s Plan of Care may not have included all patient needs. Findings: 1. Per the Home Health Certification and Plan of Care, dated 10/3/24 through 12/1/24, Patient 1 was admitted to the agency on 10/3/24 with diagnoses that included pneumonia (lung infection). The agency’s OT (Occupational Therapy – treatment to improve ability to do routine daily tasks) Evaluation for Patient 1 was dated 10/11/24 (eight days after admission). The agency’s PT (Physical Therapy – treatment to improve ability to move the body) Evaluation for Patient 1 was dated 10/11/24 (eight days after admission). 2. Per the Home Health Certification and Plan of Care, dated 11/13/24 through 1/11/25, Patient 2 was admitted to the agency on 11/13/24 with diagnoses that included surgical aftercare (treatment to recover from surgery). The agency’s ST (Speech Therapy - treatment to improve ability to speak) Evaluation for Patient 2 was dated 11/20/24 (seven days after admission). 3. Per the Home Health Certification and Plan of Care, dated 4/2/24 through 5/30/24, Patient 8 was admitted to the agency on 4/2/24 with diagnoses that included hemiplegia (inability to move part of the body). The agency’s PT Evaluation for Patient 8 was dated 4/9/24 (seven days after admission). On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, he did not require staff to complete their initial evaluation within a specific amount of time after admission. Per the agency’s policy, titled Standard HH5-2A.01, revised 11/11/16, “…The comprehensive assessment must be completed in a timely manner, consistent with patient’s immediate needs, but no later than 5 calendar days after the start of care…””

“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 plan of care was signed by the physician in a timely for three of 17 sampled patients (13, 14, 17). As a result, the agency could not ensure the physician had reviewed and approved the plan of care, treatment, and services provided. Findings: 1. Per the Home Health Certification and Plan of Care, dated 4/11/24 through 6/9/24, Patient 13 was admitted to the agency on 4/11/24 with diagnoses that included atrial fibrillation (irregular heartbeat). A review of Patient 13’s clinical record was conducted. The Certification and Plan of Care, dated 4/11/24, was signed by the physician on 5/13/24. 2. Per the Home Health Certification and Plan of Care, dated 10/4/24 through 12/2/24, Patient 14 was admitted to the agency on 8/5/24 with diagnoses that included a fractured (broken) right femur (thigh bone). A review of Patient 14’s clinical record was conducted. The Certification and Plan of Care, dated 10/4/24, was signed by the physician on 11/8/24. 3. Per the Home Health Certification and Plan of Care, dated 3/18/24 through 5/16/24, Patient 17 was admitted to the agency on 3/18/24 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-lung disease). A review of Patient 17’s clinical record was conducted. The Certification and Plan of Care, dated 3/18/24, was signed by the physician on 5/7/24. On 11/22/24 at 10:42 A.M., a joint telephone interview and record review was conducted with the Regional Director of Nursing (RDON). The RDON stated the Certification and Plan of Care should have been signed by the physician within 30 days, and Patient 13, Patient 14, and Patient 17’s plan of care had not been signed in a timely. Per the agency Standard HH5-4A Standard HH5-8A Standard HH5-8B, Verbal orders are only accepted by personnel authorized to do so by applicable State and Federal laws and regulations, as well as by the Agency’s policy and procedure. Orders are to be signed by the physician within thirty (30) days of the receipt of the order.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to complete a discharge summary for one of four sampled discharged patients (7). As a result, a summary of Patient 7’s discharge was not available for review. Findings: Per the Home Health Certification and Plan of Care, dated 5/11/24 through 7/9/24, Patient 7 was admitted to the agency on 5/11/24 with diagnoses that included clavical fracture (collar bone break). On 11/21/24 at 11:12 A.M., a review was conducted of Patient 7’s clinical Record. The Discharge Summary had a target date of 5/28/24, and was marked as not yet started. On 11/22/24 at 9:06 A.M., a telephone interview was conducted with Skilled Nurse (SN) 5. SN 5 stated, he did not remember why the discharge summary was not completed for Patient 7. On 11/22/24 at 9:44 A.M., a telephone interview was conducted with the Regional Director of Nursing (RDON). The RDON stated, there was a miscommunication at the time of Patient 7’s discharge, which caused the agency to not create the discharge summary in a timely manner. Per the agency’s policy on discharges, titled Standard 806A &1106A, dated 2010, “…The discharge summary should b e completed…The signed form becomes part of the patient’s home care record within five (5) days of discharge…””