Agape Home Care

“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 observation, interview, and record review, the facility failed to ensure the plan of care was implemented for two of seven sampled patients (Patient 1 and Patient 3) when: 1. Home Health Aide 1 (HHA 1) did not perform range of motion exercises (exercises done either independently or with assistance to improve joint flexibility and movement) or take Patient 1’s vital signs (blood pressure, temperature, pulse, respiratory rate) during a home health aide visit on February 4, 2025. This failure resulted in Patient 1 to not receive care and services as was specified in Patient 1’s plan of care including monitoring of vital signs to identify a change in the patients status and range of motion services to help improve mobility and patient independence. 2. The facility failed to notify the physician regarding two patients (Patient 1 and Patient 3) missed home health visits when: 2a. For Patient 1, there was no evidence of physician notification for a missed skilled nursing visit on December 24, 2024, and a missed Home Health Aide (HHA) visit on December 9, 2024. 2b. For Patient 3, there was no evidence of physician notification for a missed HHA visit on January 7, 2025. This failure resulted in the physician to be unaware of the missed visits and for the physician to not have an opportunity to provide additional orders for any potentially unmet care needs for Patients 1 and 3. Findings: 1. During a review of Patient 1’s “Patient Profile,” (a document which provides medical and demographic information), undated, indicated Patient 1 had a start of care date of August 8, 2024, and diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain tissue in the absence of trauma or surgery), hypertension (high blood pressure), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. During an observation on February 4, 2025, at 9:40 AM, in Patient 1’s home, HHA 1 did not perform range of motion exercises with Patient 1 and did not take Patient 1’s vital signs at any point during the home health aide visit. During an interview on February 4, 2025, at 10:15 AM, with HHA 1, HHA 1 stated she did not perform range of motion exercises with Patient 1 and stated she was not aware Patient 1’s plan of care included instructions to perform range of motion exercises. HHA 1 further stated she did not take Patient 1’s vital signs because she did not have the equipment with her which was required to take Patient 1’s vital signs. During a concurrent interview and record review on February 4, 2025, at 10:20 AM, with HHA 1, Patient 1’s “Home Health Aide Care Plan,” dated February 3, 2025, was reviewed. The care plan indicated, “Homebound status…weakness…Orders for service/treatment: Obtain BP [blood pressure], TPR [temperature, pulse, respirations] every visit…Range of Motion Exercises…special instructions: 1. Notify RN Sup. [supervisor] if Temp [temperature] > [greater than] or = [equal to] 99.5 (axilla [underarm]) or 100 (oral [by mouth]) Fahrenheit [unit of measure]; if Pulse is [greater than] 110/min; if respiratory rate is 25/min and blood pressure if systolic is [greater than] 160 mmgh and a diastolic of 100 mmhg…” Further review of the document indicated Patient 1 had the following problems listed, “…Problems…personal care…mobility and transfer…maintaining a safe environment.” HHA 1 acknowledged Range of motion exercises and vital signs were indicated as tasks on the Home Health Aide Care Plan and again confirmed she did not do them with Patient 1. During an interview on February 6, 2025, at 1:05 PM, with the Director of Patient Care Services (DOPCS), the DOPCS stated the home health aides were supposed to follow the home health aide care plan when providing services to patients during visits. The DOPCS further stated HHA 1 should have performed range of motion exercises with Patient 1 and should have taken Patient 1’s vitals during the visit conducted February 4, 2025. The DOPCS further stated the importance of taking vital signs of patients was to help identify any changes in the patients condition and range of motion exercises were important to ensure the patient can maintain mobility. During a review of the facility’s policy and procedure (P&P) titled, “Certified Home Health Aide Job Description Summary.” dated December 2006, the P&P indicated, “…The home health aide is responsible for observing patients, reporting these observations and documenting observations and care performed…Responsibilities of the home health aide include, but are not limited to, the following: …4. Taking and recording oral, rectal and axillary temperatures, pulse, respiration and blood pressure when ordered…5. Assisting in ambulation and exercise according to the plan of care. 6. Performing range of motion and other simple procedures as an extensional therapy service as ordered…10. Reporting on patient’s condition and significant changes to the assigned nurse…” 2a. A review of Patient 1’s “Patient Profile,” (a document which provides medical and demographic information), undated, indicated Patient 1 had a start of care date of August 8, 2024, and diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain tissue in the absence of trauma or surgery), hypertension (high blood pressure), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. During a review of Patient 1’s “Home Health Certification and Plan of Care,” with a certification period of December 6, 2024, to February 3, 2025, the plan of care indicated a physician’s order for skilled nursing visits to occur every week for nine weeks and HHA visits two times a week for eight weeks. Further review of the “Home Health Certification and Plan of Care,” indicated nursing services was to include observation/assessment of vital signs and all body systems, provide teaching instructions on disease process, management and appropriate actions to take control of disease, activity level, diet and medication regimen, pain control and management, identify and evaluate s/s reportable to medical doctors, and for the evaluation of the patient’s need for possible modifications of treatment or initiation of additional medical procedures until the patient’s treatment is stabilized. Home Health aid services were ordered to provide assistance with personal care and activities of daily living (ADL’s - a term used to collectively describe fundamental skills required to care for oneself, such as eating, bathing, and mobility). During a review of Patient 1’s Electronic Health Record (EHR – an electronic health record), the EHR indicated Patient 1 had a missed skilled nursing visit on December 24, 2024, and a missed HHA visit on December 9, 2024. There was no documented evidence in Patient 1’s EHR which indicated the physician was made aware of the missed visits. 2b. A review of Patient 3’s “Patient Profile,” undated, indicated Patient 3 had a start of care date of August 8, 2023, and diagnoses which included rheumatoid arthritis (condition that causes pain, swelling and stiffness in the joints), hypertension, and abnormalities of gait (walking) and mobility. During a review of Patient 3’s “Home Health Certification and Plan of Care,” with a certification period of January 29, 2025, to March 29, 2025, the plan of care indicated a physician’s order for HHA visits one time a week for nine weeks and the purpose of the visits was to provide assistance with personal care and ADL’s. During a review of Patient 3’s EHR, the EHR indicated Patient 3 had a missed HHA visit on January 7, 2025. There was no documented evidence in Patient 3’s EHR which indicated the physician was made aware of the missed visit. During an interview on February 5, 2025, at 12:28 PM, with the Office Manager (OM), the OM stated the physician was supposed to be notified of all missed visits and she was the individual who usually notified the physicians of the missed visits. During a concurrent interview and record review on February 5, 2025, with the OM, the OM reviewed Patient 1’s and Patient 3’s EHR and stated there was no evidence a physician was made aware of Patient 1’s missed visits on December 24, 2024 (skilled nursing visit) and December 9, 2024 (home health aide visit) or Patient 3’s missed visit on January 7, 2025 (home health aide visit) During an interview on February 6, 2025, at 4:10 PM, with the Director of Patient Care Services (DOPCS), the DOPCS stated when there was a missed home health visit, the physician was supposed to be notified. During a concurrent interview and record review on February 5, 2025, at 12:25 PM, with the Administrator (ADMIN), the ADMIN stated the facility did not have a policy and procedure (P&P) regarding notifying the physician about missed home health visits but stated it would fall under the P&P titled, “Monitoring Patient’s Response/Reporting to physician,” undated, the P&P was reviewed and indicated, “…3. The patient’s physician will be contacted on the same day when any of the following occur: …F. When there is a problem implementing the plan of care.” The ADMIN stated he considered a missed visit to be a time in which there was a problem implementing the plan of care.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to ensure they had a performance improvement project (PIP – a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) in progress or in development. This failure resulted in the facility to have missed opportunities for the examination and improvement in care or services in areas that the facility identifies as needing attention. Findings: During a concurrent interview and record review on February 6, 2025, at 11:40 AM, with the Administrator (ADMIN), the ADMIN stated the facility did not have a performance improvement project in progress or in development. The ADMIN further stated the facility only had quality metrics which they have been collecting data for since 2006 (falls, hospitalizations, infections etc.) and the data was reviewed quarterly (every 3 months). The facility’s QAPI binder was reviewed and there was no documentation of a performance improvement project either in development, in progress, or previously completed. The ADMIN stated he was not aware of the requirement to have a performance improvement project and the facility did not have any policies or procedures (P&P) relating to performance improvement projects.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure employee files for staff included completed orientation checklists, reference verification checks, and background checks as specified in the facility’s policies and procedures (P&P) when: 1. A home health aide (HHA 1), two Licensed Vocational Nurses (LVN 1 and LVN 2), and a Registered Nurse (RN 1), did not have completed orientation checklists. 2. The Director of Patient Care Services (DOPCS), LVN 1, and RN 1, did not have verification of references documented. 3. RN 1 did not have a background check on file. These failures resulted in the facility to not have documented evidence that all staff underwent orientation training and background checks prior to being hired. This had the potential for staff to be unfamiliar regarding organizational processes for patient quality of care and safety and for potential mistreatment or abuse of patients. Findings: 1. During an interview on February 3, 2025, at 3:17 PM, with the Administrator (ADMIN), the ADMIN stated all staff were supposed to complete orientation training upon hire which included the completion of an orientation checklist titled, “Personnel Orientation Checklist,” dated December 2006. During a review of the facility document titled, “Personnel Orientation Checklist,” dated December 2006, the document included four columns. The first column had multiple topics listed which included but was not limited to “…criminal background check…general orientation to organization…organization safety review…infection prevention and control within the organization…confidentiality of organization and patient information…home safety issues…infection control practices (specific to the home setting)…screening for abuse and neglect…patient rights and responsibilities…emergency preparedness…and cultural diversity and sensitivity. The second column indicated “Date completed”, the third column indicated “ Orientation by whom” and the fourth column indicated, “Personnel initials.” During a record review of six employee files, four of six staff had incomplete orientation documentation as indicated below: 1a. HHA 1’s “Personnel Orientation Checklist,” undated, located in the employees personnel file was completely blank in all four columns (date completed, orientation by whom, and personnel initials). In addition, the form did not have the employees name or date of hire indicated anywhere on the form. 1b. LVN 1’s “Personnel Orientation Checklist,” had LVN 1’s name on it and was dated March 07, 2018 (approximately 7 years prior) and was blank next to all orientation topics in the columns where “date completed, orientation by whom, and personnel initials” were indicated. 1c. LVN 2’s “Personnel Orientation Checklist,” had LVN 2’s name on it and was dated November 23, 2015 (approximately 9 years prior and was blank next to all orientation topics in the columns where “date completed, orientation by whom, and personnel initials” were indicated. 1d. RN 1’s Personnel Orientation Checklist,” had RN 1’s name on it and was dated May 13, 2022 (approximately 2.5 years prior) and was blank next to all orientation topics in the columns where “date completed, orientation by whom, and personnel initials” were indicated. During a concurrent interview and record review on February 3, 2025, at 3:17 PM, with the ADMIN, HHA 1, LVN 1, LVN 2, and RN 1’s “Personnel Orientation Checklists,” were reviewed. The ADMIN stated the orientation checklists were incomplete and were supposed to be completed when the staff were first hired, but they were not completed and it was an oversight. During a review of the facility’s policy and procedure (P&P) titled, “Orientation,” dated December 2006, the policy indicated, “Purpose. To provide guidelines for the organization’s orientation process. Policy – All staff will be required to attend an initial orientation program upon employment. Staff orientation promotes safe and effective job performance…All staff will demonstrate knowledge and proficiency in skills appropriate to their assigned roles and responsibilities during the orientation period…2. The orientation process, for all staff will consist of both didactic and field supervision. Observation visits will be made by a supervisor to assess the skills demonstrated by new staff as well as reinforce the information presented during classroom time…5. A personnel Checklist (see “Personnel Orientation Checklist” Addendum 1-010.A) will be completed for all new staff. New staff will sign and date when their orientation has been completed. 6. The assigned supervisor will sign and date when new staff have completed all the required activities for all patients receiving intermittent home health services…” 2. During an interview on February 3, 2025, at 3:05 PM, with the ADMIN, the ADMIN stated staff were supposed to have reference checks performed as part of the hiring process. The ADMIN further stated an individual from the facility was supposed to call the staff members reference contacts and ask questions and complete the “Evaluator” section of the reference check form titled, “Verification of Employment”. The ADMIN stated reference checks were either done via phone, fax or mail. During a concurrent interview and record review on February 3,2025, at 3:06 PM, with the ADMIN, the employee files for six staff members were reviewed. Three of the six staff members (DOPCS, LVN 1, and RN 1) had “Verification of Employment” forms, which were blank in the “performance evaluation” section. The “performance evaluation” section included six questions which were unanswered [left blank] (skill level, cooperation, initiative, attendance, attitude, appearance) and blanks were indicated where “over the phone…via fax…or via email,” where indicated. Furthermore, the “name of evaluator…position…date” was also left blank and was not completed. The ADMIN acknowledged the verification of employment forms were blank in the “evaluator” section and stated someone was supposed to check on references and complete the “evaluator” section of the forms for the DOPCS, LVN 1, and RN 1, but they did not. During an interview on February 3, 2025, at 3:31 PM, with the ADMIN, the ADMIN stated a previous employee (who no longer worked at the facility) used to do the reference checks but now it was the responsibility of either him (the ADMIN), or the Office Manager (OM). During a review of the facility’s policy and procedure (P&P) titled, “Selection/Hiring of Personnel,” dated December 2006, the policy indicated, “Purpose – To specify the criteria for selection of staff to meet the care needs of appropriate patients. Policy – The organization defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and service goals…Hiring…1. An individual seeking employment will complete an application, including information and verification about education, work experience, competencies, job history, and references, and have a personal interview…6. At least one (1) preferably two (2) references, either telephone and/or written, will be obtained prior to an offer of employment…15. Verification of the above will be documented.” 3. During a concurrent interview and record review on February 3, 2025, at 3:48 PM, with the ADMIN, RN 1’s employee file was reviewed. There was no evidence a background check was obtained by the facility at any time prior to employing RN 1 and no evidence a background check was performed for RN 1 at any time after employment. The ADMIN stated it was his responsibility to perform background checks on staff upon hire. The ADMIN further stated the facility should have had a background check done for RN 1 but they did not, and it was an oversight. During a review of the facility’s policy and procedure (P&P) titled, “Selection/Hiring of Personnel,” dated December 2006, the policy indicated, “Purpose – To specify the criteria for selection of staff to meet the care needs of appropriate patients. Policy – The organization defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and service goals…Hiring…2. A criminal background check will be obtained for positions required by law, regulation or organizational policy…15. Verification of the above will be documented.””