Adept Home Health Services, Inc.

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on interview, and record review, the facility failed to ensure its emergency preparedness plan and policies and procedures were reviewed and updated (as necessary) at least every two (2) years. This failure resulted in the agency to not have evidence that its emergency preparedness plan and policies and procedures were reviewed and updated to reflect current agency emergency procedures, contained accurate information regarding emergency contacts, and did not need changes or amendments since its last review. This placed all 32 patients on census at risk for potential harm to their health and safety in the event of an emergency. During an interview on June 19, 2025, at 10:27 AM, with the Administrator (ADMIN/DPCS), the ADMIN/DPCS stated the facility did not perform a review of the emergency preparedness plan or policies and procedures at least every two years. During an interview on June 19, 2025, at 10:29 AM, with the Office Manager (OM), the OM stated the facility did not perform a review of the emergency preparedness plan every two years and were therefore unable to show documented evidence the emergency preparedness plan and policies and procedures were reviewed within the last two years. During a concurrent interview and record review on June 19, 2025, at 10:30 AM, with the ADMIN/DPCS, the facilities policy and procedure (P&P) titled, “Emergency Operation Plan (EOP),” (undated), was reviewed. The P&P indicated, “1. The Emergency/Disaster Plan provides an orderly procedure to be implemented in an emergency to assure that the health care needs of patients continue to be met…3. The Agency must maintain documentation of compliance with emergency preparedness…8. The policy and procedure on Emergency Preparedness Plan will be reviewed and updated annually.” The ADMIN/DPCS stated the facility did not perform a regular review of the EOP P&P at least every two years and stated he thought they were just required to do emergency preparedness training with staff every year.”

“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 evaluation and improvement in care or services in areas that the facility identifies as needing attention. During an interview on June 19, 2025, at 2:20 PM, with the Administrator/Director of Patient Care Services (ADMIN/DPCS), when asked to see evidence of performance improvement projects the agency has undertaken, the ADMIN/DPCS stated the agency did not have a performance improvement project they were working on and had no evidence of a performance improvement project they had undertaken. The ADMIN/DPCS stated the agency needed to create a project to work on. During an interview on June 19, 2025, at 2:23 PM, with the Quality Assurance staff member (QA), the QA stated the agency did not have a performance improvement project they were working on and that the Quality Assurance Performance Improvement (QAPI) program generally involved collection of data on various quality indicators but they did not have a project in process. The QA further stated they needed to create a performance improvement project to work on. During a review of the facility’s policy and procedure (P&P) titled, “[Name of HHA facility],” (undated), the P&P indicated, “…The purpose of the Agency QAPI program is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities…Objectives…To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained. To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for two of three patients in which home visits were conducted (Patient 2 and 3) when: 1. During wound care for Patient 2, Quality Assurance Staff (QA) did not change her gloves after removing old wound dressings and wore the same gloves when applying new wound dressings to five of Patient 2’s wounds. 2. QA used her clipboard (with paperwork) as a barrier when she placed it (clipboard) on a table in Patient 2’s home and then placed her nursing bag on top of her clipboard as a barrier. Additionally, Physical Therapist 1 (PT 1) placed his supply bag directly on a table in Patient 3’s living room and did not use a barrier between his supply bag and Patient 3’s table. These failures resulted in increased risk of wound infection and/or cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one or object to another) of the environment for Patients 2 and 3. 1. During an observation on June 18, 2025, at 9:55 AM, in Patient 2’s home, with QA, the QA removed the dressings of five different wounds located on Patient 2’s abdominal area. The QA then cleaned all five wounds and applied new gauze dressings to all five wounds using the same pair of gloves she used to remove the old gauze wound dressings. During an interview on June 18, 2025, at 10:40 AM, with QA, the QA stated she didn’t realize that she did not remove her gloves after taking off the old wound dressings. The QA further stated she should have removed her gloves and put on new gloves prior to putting on the new wound dressing but she was nervous. During an interview on June 18, 2025, at 3:31 PM, with the RN Supervisor (RNS), the RNS stated during wound care, gloves should be worn and changed at least three times. The RNS further stated gloves should be worn during the removal of wound dressings, then a new pair of gloves should be put on during the cleaning of wounds, and a new pair of gloves should be used when placing new dressings on the wounds. During a review of the facility’s policy and procedure (P&P) titled, “Use of Protective Equipment,” (undated), the P&P indicated, “A. Gloves…clean gloves are worn for any procedure/patient care whenever there is a risk of contact with body substances, mucous membranes, or non-intact skin…gloves are changed between each procedure to prevent any cross contamination. Each time gloves are removed, hands shall be washed…” During a review of the facility’s P&P titled, “Hand washing,” (undated), the policy indicated, “Hand Washing is the single most effective means of infection control. The purpose of hand washing is to prevent the transmission of infectious agents from person-to-person. Proper hand washing removes transient microbial contamination acquired through contact with patients, body fluids/substances, or environmental sources. Guidelines: 1. Employees are required to wash their hands: …c. After removal of gloves or other personal protective equipment…” 2. During an observation on June 18, 2025, at 9:55 AM, with QA, in Patient 2’s home, the QA placed her clipboard with paperwork onto a table in Patient 2’s home. The QA then placed her nursing supply bag onto her clipboard and paperwork. During an interview on June 19, 2025, at 3:09 PM, with QA , QA stated she was supposed to place her nursing supply bag onto a barrier while in Patient 2’s home and should not have placed her belongings on her clipboard as a barrier. During an observation on June 18, 2025, at 11:05 AM, with Physical Therapist 1 (PT 1), in Patient 3’s home, PT 1 placed his supply bag directly onto a table in Patient 3’s home and did not place his supply bag on a barrier. During an interview on June 18, 2025, at 11:58 AM, with PT 1, PT 1 stated he never usually placed a barrier underneath his belongings while in the patients home and it was not his normal practice. During an interview on June 18, 2025, at 3:30 PM, with the RNS, the RNS stated staff should be using a barrier to place their supply bags on while in the patient’s home. The RNS further stated the purpose of using a barrier was to help prevent the spread of bacteria. During an interview on June 18, 2025, at 3:40 PM, with the Administrator/Director of Patient Care Services (ADMIN/DPCS), the ADMIN/DPCS stated the facility did not have a policy and procedure regarding staff using a barrier to place their supply bags on while in the patient’s home.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on interview, and record review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI - a data-driven, systematic approach to improving safety and quality in healthcare settings) committee gathered information regarding the agency’s performance in conducting Licensed Vocational Nurse (LVN) joint supervisory visits (a Registered Nurse’s [RN] on-site assessment of a patient receiving care from a LVN. These visits ensure the patient’s needs are being met and the care plan is being followed, with the RN monitoring the quality of care and the LVN’s performance). This failure resulted in the agency to not follow its own policies regarding QAPI tasks and for the agency to not identify that LVN joint supervisory visits (by an RN) were not being documented as being performed. During an interview on June 19, 2025, at 2:12 PM, with the Administrator/Director of Patient Care Services (ADMIN/DPCS), the ADMIN/DPCS stated supervisory visits for LVNs were supposed to be a joint visit (RN and LVN onsite at the same time) and were supposed to be completed every month but had been missed lately by the agency. The ADMIN/DPCS further stated the supervisory visits were supposed to be documented. During an interview on June 19, 2025, at 2:38 PM, with the Registered Nurse Supervisor (RNS), the RNS stated the agency has not been appropriately documenting RN supervisory visits for oversight of the LVNs. During a review of the facility policy and procedure (P&P) titled, “Annual QAPI Program Review,” (undated), the policy indicated, “…Monitoring activity - Staff Review…Data source -…supervisory visit and staff evaluations…Sample size – 10% of current census [10 percent of patient charts to be reviewed and audited]…Monitoring frequency – Quarterly…” During a concurrent interview and record review on June 19, 2025, at 3:30 PM, with the Quality Assurance Staff Member (QA), the QA stated as part of the QAPI program, the agency audited ten percent (10%) of patient charts to review for certain quality indicators. The P&P titled, “Annual QAPI Program Review,” (undated), was reviewed. The QA acknowledged the document indicated supervisory visits were one of the items which were going to be monitored. When asked what data the QAPI collected regarding its completion of RN supervisory visits for LVNs, the QA stated the QAPI program only tracked documentation regarding CHHA supervisory visits and did not have data or information regarding the completion RN supervisory visits for LVNs. During a review of the facility’s P&P titled, “[name of facility],” (undated), the policy indicated “Purpose – The purpose of the Agency QAPI program is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice…””

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of seven sampled patients (Patient 6) received skilled nursing home health visits in the frequency as ordered by the physician for the certification period of March 15, 2025, through to May 13, 2025. This had the potential for Patient 6 to have unmet care needs and for Patient 6 to experience a decline in her overall health status and functioning. A review of Patient 6’s “Home Health Certification and Plan of Care” (contains medical and demographic information) with a certification period of March 15, 2025, through May 13, 2025, the plan of care indicated Patient 6 had a start of care date of January 14, 2025. Additionally, the plan of care indicated Patient 6 had diagnoses which included heart failure, hypertension (high blood pressure), epilepsy (seizure disorder), and history of falls. During further review of Patient 6’s “Home Health Certification and Plan of Care,” with a certification period of March 15, 2025, through May 13, 2025, the plan of care indicated, Patient 6 was supposed to receive skilled nursing home health visits at a frequency of two times a week for a total of eight weeks (as ordered by the physician), and then one visit on week nine. The plan further indicated, “Goals…SN [skilled nursing] to assess: -all body systems, particularly cardiovascular, respiratory, integumentary [skin] and musculoskeletal status – response to new medications – ambulation [walking] and endurance – home safety measures…” During a review of Patient 6’s “Visits Compliance Calendar” (a calendar which shows completed home health visits), dated March 15, 2025, through May 13, 2025, the calendar indicated Patient 6 only received one skilled nursing home health visit per week (instead of two as ordered by the physician) for the weeks between April 13, 2025, and May 10, 2025. During a concurrent interview and record review on June 18, 2025, at 2:50 PM, with the Clerical Staff (CS), Patient 6’s clinical record was reviewed. The CS stated Patient 6 was supposed to have two skilled nursing home health visits per week for eight weeks but from April 13, 2025, through May 10, 2025 (total of four weeks) the patient only received one a week. The CS further stated she was unable to find documented evidence as to why the patient did not receive skilled nursing visits as was ordered. During a concurrent interview and record review on June 18, 2025, at 2:59 PM, with the Registered Nurse Supervisor (RNS), Patient 6’s clinical record was reviewed. The RNS stated she was unable to find documented evidence of why Patient 6 did not receive two skilled nursing home health visits a week for four consecutive weeks and instead only received one. The RNS further stated the agency did not receive a physician’s order to decrease the frequency of home health visits to only one time a week. During an interview on June 18, 2025, at 3:15 PM, with the Administrator/Director of Patient Care Services (ADMIN/DPCS), the ADMIN/DPCS stated patients should be receiving home health visits in the frequency as ordered by the physician and the frequency of visits should never be changed without a physicians order. During a review of the facility’s policy and procedure (P&P) titled, “Physician Orders,” (undated), the P&P indicated, “1. Physician’s orders (physician’s medical plan of treatment) should specify services, treatment and supplies to be provided by the agency…” During a review of the facility’s P&P titled, “Organization,” (undated), the policy indicated, “3…Home care services are to be ordered by a physician and will include a plan of treatment…services must be reasonable and necessary to the treatment of an illness or injury…””

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure they had documented evidence that a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for three of seven sampled patients (Patients 3, 6 and 7) when there was no documentation indicating supervisory visits were performed. This failure had the potential to cause substandard LVN care practices to go unrecognized and uncorrected which can compromise the Patients 3, 6, and 7 health and safety. a. A review of Patient 3’s “Home Health Certification and Plan of Care” (contains medical and demographic information) with a certification period of April 17, 2025, to June 15, 2025, indicated a start of care date of December 18, 2024. Additionally, the plan of care indicated Patient 3 had diagnoses which included congestive hear failure (condition in which the heart can’t pump enough blood to meet the body’s needs), type 2 diabetes mellitus (a condition in which the body has trouble regulating blood sugar levels), and end stage renal disease (kidney failure). During further review of Patient 3’s “Home Health Certification and Plan of Care,” with a certification period of April 17, 2025, to June 15, 2025, the plan of care indicated Patient 3 was supposed to receive skilled nursing home health visits once a week for a total of eight weeks as ordered by the physician. During a review of Patient 3’s “Visits Compliance Calendar” (a calendar which shows completed home health visits), dated April 17, 2025, through June 15, 2025, the calendar indicated Patient 3 received skilled nursing home health visits by an LVN on six of the eight visits performed. Two visits, one on May 5, 2025, and another on June 13, 2025, were performed by an RN. During a review of Patient 3’s “Clinical Nursing Note” (a document where licensed nurses record information for each home health visit), dated May 5, 2025, and June 13, 2025, (the only home health visits which were conducted by an RN) the notes did not have any indication that the RN performed a “supervisory visit.” Further review of the documents indicated the section “RN supervisory visit…Yes – No” was left blank and unanswered. Additionally, the section which indicated, “Joint LVN Visit…Yes – No” was left blank and unanswered and there was no other evidence in Patient 3’s clinical record to indicate a supervisory visit was performed for the LVN. During an interview on June 19, 2025, at 2:12 PM, with the Administrator/Director of Patient Care Services (ADMIN/DPCS), the ADMIN/DPCS stated supervisory visits for LVNs were supposed to be a joint visit (RN and LVN onsite at the same time) and were supposed to be completed every month but had been missed lately by the agency. The ADMIN/DPCS further stated the supervisory visits were supposed to be documented. During a concurrent interview and record review on June 19, 2025, at 2:15 PM, with the Registered Nurse Supervisor (RNS), Patient 3’s clinical record was reviewed. The RNS stated the agency did not have documented evidence indicating an RN supervisory visit or Joint LVN visit was conducted for Patient 3 during the certification period of April 17, 2025, to June 15, 2025. b. A review of Patient 6’s “Home Health Certification and Plan of Care,” with a certification period of March 15, 2025, to May 13, 2025, indicated a start of care date of January 14, 2025. Additionally, the plan of care indicated Patient 6 had diagnoses which included congestive heart failure, epilepsy (seizure disorder), and history of falling. During further review of Patient 6’s “Home Health Certification and Plan of Care,” with a certification period of March 15, 2025, through May 13, 2025, the plan of care indicated, Patient 6 was supposed to receive skilled nursing home health visits at a frequency of two times a week for a total of eight weeks as ordered by the physician. During a review of Patient 6’s “Visits Compliance Calendar,” dated March 15, 2025, through May 13, 2025, the calendar indicated Patient 6 received skilled nursing home health visits by an LVN on nine out of eleven visits performed. Two visits, one on April 4, 2025, and another on April 30, 2025, were performed by an RN. During a review of Patient 6’s “Clinical Nursing Note,” dated April 4, 2025, and April 30, 2025 (the only home health visits which were conducted by an RN), the notes did not have any indication that the RN performed a “supervisory visit.” Further review of the documents indicated the section “RN supervisory visit…Yes – No” was left blank and unanswered. Additionally, the section which indicated, “Joint LVN Visit…Yes – No,” was left blank and unanswered and there was no other evidence in Patient 6’s clinical record to indicate a supervisory visit was performed for the LVN. During a concurrent interview and record review on June 19, 2025, at 2:20 PM, with the RNS, Patient 6’s clinical record was reviewed. The RNS stated the agency did not have documented evidence indicating an RN supervisory visit or Joint LVN visit was conducted for Patient 6 during the certification period of March 15, 2025, through May 13, 2025. c. A review of Patient 7’s “Home Health Certification and Plan of Care,” with a certification period of April 8, 2025, to June 6, 2025, indicated a start of care date of February 7, 2025. Additionally, the plan of care indicated Patient 7 had diagnoses which included multiple fractures of the pelvis (fractured bones of the bony structure located inside your hips, buttocks and pubic region), Chronic Obstructive Pulmonary Disease (COPD – a progressive lung disease that makes it hard to breathe), and prostate cancer (cancer of the prostate gland). During further review of Patient 7’s “Home Health Certification and Plan of Care,” with a certification period of April 8, 2025, to June 6, 2025, the plan of care indicated, Patient 7 was supposed to receive skilled nursing home health visits at a frequency of one time a week for a total of nine weeks as ordered by the physician. During a review of Patient 7’s “Visits Compliance Calendar,” dated April 8, 2025, through June 6, 2025, the calendar indicated Patient 7 received skilled nursing home health visits by an LVN on seven of nine visits performed. Two visit, one on May 7, 2025, and another on May 20, 2025, were performed by an RN. During a review of Patient 7’s “Clinical Nursing Note,” dated May 7, 2025, and May 20, 2025 (the only home health visits which were conducted by an RN), the notes did not have any indication that the RN performed a “supervisory visit.” Further review of the documents indicated the section which indicated, “Joint LVN Visit…Yes-No,” was left blank and unanswered and there was no other evidence in Patient 7’s clinical record to indicate a supervisory visit was performed for the LVN. During a concurrent interview and record review on June 19, 2025, at 2:30 PM, with the RNS, Patient 7’s clinical record was reviewed. The RNS stated the agency did not have documented evidence indicating an RN supervisory visit or Joint LVN visit was conducted for Patient 7 during the certification period of April 8, 2025, through June 6, 2025. During an interview on June 19, 2025, at 2:38 PM, with the RNS, the RNS stated the agency has not been appropriately documenting RN supervisory visits for oversight of the LVNs. During a review of the facility’s policy and procedure (P&P) titled, “Supervisory Visits,” (undated), the P&P indicated, “Policy: Documentation of RN Supervisory Visit…RN supervisory visit will be written on a clinical note. Documented evidence will be reflected on clinical note and patient/patient caregiver will sign clinical note to verify visit was made with date and time.””