Ace Home Health Care & Hospice, Inc.

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on interview and record review for one of two sampled patients (Patient 1), the Agency failed to meet the Condition of Participation for Care Planning, Coordination, Quality of Care when the HHA did not follow the established plan of care when Home Health Aide (HHA) 1 did not assist Patient 1 with ambulation while Patient 1 ambulated without a walker. Refer to deficiency at G572 The cumulative severity and intensity of this deficiency resulted in the failure of the facility to meet 484.60, Care Planning, Coordination, Quality of Care. See tags G572”

“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 for one of two sampled patients (Patient 1), the agency failed to provide services according to plan of care when Home Health Aide (HHA) 1 did not assist Patient 1 with ambulation while Patient 1 ambulated without a walker. This failure resulted in Patient 1 to fall and taken to the hospital via 911, where Patient 1 received emergency treatment for diagnoses that included subarachnoid hemorrhage (bleeding in the space between the brain and the protective membranes, meninges), left facial fracture, fracture of one left rib, and fracture of left wrist. Patient 1 was then transferred to another facility (trauma hospital) for trauma management where additional injuries that included multiple left rib fractures, from 2nd to 7th, the 4th and 5th ribs fractured in two places, were found. During a review of Patient 1’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 4/4/25-6/2/25, the “HHCPOC” indicated Patient 1 was to receive Home Health Aide (HHA) services twice weekly for seven weeks for assistance with ADLs (activities of daily living such as personal hygiene, showers, ambulation). During a review of Patient 1’s “Start of Care (SOC)” (the initial assessment visit by a clinician when a patient begins receiving home health services) dated 4/4/25, the SOC indicated, Patient 1 required the use of two-handed device to walk alone (such as a walker) on a level surface and/or required human supervision or assistance to negotiate stairs or steps or uneven surfaces. Patient 1 had functional limitation with ambulation and had vision deficit. Record review of the document titled “Care Planning Process” last revised May 2024 indicated, based on the assessment, services to be provided will be based on the prioritized needs of the patient. During a review of the HHA visit dated 4/15/25 and signed by HHA 1, the visit indicated “Upon arrival, patient agreed to shower. [Patient 1] got out [of the chair] to go get [shampoo], as I awaited [Patient 1], I heard a loud noise patient had a fall in the hallway…” During a telephone interview on 6/4/25 at 12:15 p.m. with HHA 1, HHA 1 stated having reviewed Patient 1’s “Plan of Care” before showing up for the visit on 4/15/25, and knew Patient 1 was a fall risk and needed a walker for safety. When HHA 1 arrived at the home, Patient 1 was already in the bathroom. HHA 1 stated Patient 1’s walker was nowhere in or near the bathroom. HHA 1 stated, as they prepared for shower, they both realized there was no shampoo. HHA 1 stated Patient 1 ambulated out of the bathroom to get the shampoo, without a walker, while HHA 1 waited. HHA 1 stated hearing a loud noise from the hallway few moments later. HHA 1 stated she walked out of the bathroom and found Patient 1 in the hallway close to the stairs, on the floor, lying on the left side. HHA 1 stated calling for Family Member (FM) 1 who was upstairs for help. FM 1 called 911 and Patient 1 was taken to the hospital. During a telephone interview on 6/4/25 at 12:52 p.m. with Registered Nurse (RN) 1, RN 1 stated Patient 1 was a fall risk because of unsteady gait, spinal curvature (hunchback) and a wound on the left foot that affected Patient 1’s ability to walk. RN 1 also stated Patient 1 was started on a new medication that caused dizziness. RN 1 stated it was important for Patient 1 to have a walker when ambulating. During an interview on 6/4/25 at 1:10 p.m. with Director of Patient Care Services (DPCS), DPCS stated, after the fall incident was reviewed, the agency determined a performance evaluation focused on safety would be done with HHA 1, making sure HHA 1 agreed with HHA Care Plan. During a concurrent interview and record review on 6/19/25 at 12:04 p.m. with DPCS, Patient 1’s HHA Care Plan dated and signed by RN 1 on 4/4/25 was reviewed. The HHA Care Plan indicated safety precautions that included fall precautions, keep pathways clear, safety in ADLs, and use of assistive devices. DPCS stated ADLs included dressing, transferring, dumping trash, and ambulation. DPCS stated Patient 1 needed a walker for safety. During a review of the “ED (Emergency Department) Provider Notes” dated 4/15/25, the “ED Provider Notes” indicated Patient 1 required admission to the hospital for multiple traumatic injuries that included trauma, closed nondisplaced fracture of the left frontal bone, closed left wrist fracture, subarachnoid hemorrhage, and closed fracture of multiple ribs on the left side. During a telephone interview on 6/23/25 at 12:03 p.m. with FM 1, FM 1 stated Patient 1 was at the bottom of the stairs, lying on his side. FM 1 stated the downstairs bathroom where HHA 1 waited, was about 20 feet from where Patient 1 was found, and one would not have any visual of the hallway or the stairs, from the bathroom, because of a wall that separated both spaces. FM 1 stated Patient 1’s disorientation has gotten worse after the fall incident. Record review of the document titled “Job Descriptions” last revised November 2017, indicated the essential job functions/responsibilities of a Home Health Aide included the following: providing hands-on personal care like baths, shampoo, assisting the patient with toileting activities, assisting in ambulation and exercise according to the plan of care, and meeting safety needs of patients and using equipment safely and properly. During a review of Patient 1’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 4/4/25-6/2/25, the “HHCPOC” indicated, Patient 1 was to receive Home Health Aide (HHA) services twice weekly for seven weeks for assistance with ADLs (activities of daily living such as personal hygiene, showers, ambulation). During a review of Patient 1’s “Start of Care (SOC) [the initial assessment visit by a clinician when a patient begins receiving home health services], dated 4/4/25, the SOC indicated, Patient 1 required the use of two-handed device to walk alone (such as a walker) on a level surface and/or required human supervision or assistance to negotiate stairs or steps or uneven surfaces. Patient 1 had functional limitation with ambulation and had vision deficit. Record review of the document titled “Care Planning Process” last revised May 2024 indicated, based on the assessment, services to be provided will be based on the prioritized needs of the patient. During a review of the HHA visit dated 4/15/25 and signed by HHA 1, the visit indicated “Upon arrival, patient agreed to shower. [Patient 1] got out [of the chair] to go get [shampoo], as I awaited [Patient 1], I heard a loud noise patient had a fall in the hallway…” During a telephone interview on 6/4/25 at 12:15 p.m. with HHA 1, HHA 1 stated having reviewed Patient 1’s “Plan of Care” before showing up for the visit on 4/15/25, and knew Patient 1 was a fall risk and needed a walker for safety. When HHA 1 arrived at the home, Patient 1 was already in the bathroom. HHA 1 stated Patient 1’s walker was nowhere in or near the bathroom. HHA 1 stated, as they prepared for shower, they both realized there was no shampoo. HHA 1 stated Patient 1 ambulated out of the bathroom to get the shampoo, without a walker, while HHA 1 waited. HHA 1 stated hearing a loud noise from the hallway few moments later. HHA 1 stated she walked out of the bathroom and found Patient 1 in the hallway close to the stairs, on the floor, lying on the left side. HHA 1 stated calling for Family Member (FM) 1 who was upstairs for help. FM 1 called 911 and Patient 1 was taken to the hospital. During a telephone interview on 6/4/25 at 12:52 p.m. with Registered Nurse (RN) 1, RN 1 stated Patient 1 was a fall risk because of unsteady gait, spinal curvature (hunchback) and a wound on the left foot that affected Patient 1’s ability to walk. RN 1 also stated Patient 1 was started on a new medication that caused dizziness. RN 1 stated it was important for Patient 1 to have a walker when ambulating. During an interview on 6/4/25 at 1:10 p.m. with Director of Patient Care Services (DPCS), DPCS stated, after the fall incident was reviewed, the agency determined a performance evaluation focused on safety would be done with HHA 1, making sure HHA 1 agreed with HHA Care Plan. During a concurrent interview and record review on 6/19/25 at 12:04 p.m. with DPCS, Patient 1’s HHA Care Plan dated and signed by RN 1 on 4/4/25 was reviewed. The HHA Care Plan indicated safety precautions that included fall precautions, keep pathways clear, safety in ADLs, and use of assistive devices. DPCS stated ADLs included dressing, transferring, dumping trash, and ambulation. DPCS stated Patient 1 needed a walker for safety. During a review of the “ED (Emergency Department) Provider Notes” dated 4/15/25, the “ED Provider Notes” indicated Patient 1 required admission to the hospital for multiple traumatic injuries that included trauma, closed nondisplaced fracture of the left frontal bone, closed left wrist fracture, subarachnoid hemorrhage, and closed fracture of multiple ribs on the left side. During a telephone interview on 6/23/25 at 12:03 p.m. with FM 1, FM 1 stated Patient 1 was at the bottom of the stairs, lying on his side. FM 1 stated the downstairs bathroom where HHA 1 waited, was about 20 feet from where Patient 1 was found, and one would not have any visual of the hallway or the stairs, from the bathroom, because of a wall that separated both spaces. FM 1 stated Patient 1’s disorientation has gotten worse after the fall incident. Record review of the document titled “Job Descriptions” last revised November 2017, indicated the essential job functions/responsibilities of a Home Health Aide included the following: providing hands-on personal care like baths, shampoo, assisting the patient with toileting activities, assisting in ambulation and exercise according to the plan of care, and meeting safety needs of patients and using equipment safely and properly.”

“Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency did not maintain educational records for three of four Home Health Aides (HHA 1, 2, 3 and 4) reviewed. This resulted in an inability to assess whether the HHAs’ skills were current. Record review of the document “Personnel Development,” last revised May 2024, indicated the agency will provide in-services, training sessions, and continuing education. Documentation of employees’ attendance will be requested and, in the personnel file, and will be maintained by the organization. It also indicated “All clinical staff and home health aides will attend twelve (12) hours of in-service education during each twelve (12) month period. Training verification will be stored in an accessible location with the DPCS (Director of Patient Care Services) and HR (Human Resources) Department.” During a concurrent interview and record review on 6/4/2025 at 11:01 a.m. with DPCS, in-service training attendance for home health aides from May 2024 to May 2025 were reviewed. DPCS confirmed HHA 1, 2, and 4 did not have record of the total 12-hour in-service training in their files.”