Brilliant Health Home Care 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 home health agency (HHA) failed to ensure that all staffs must be trained in emergency preparedness and conduct the emergency drill annually. This failure resulted in the staff not being trained on the emergency preparedness which had the potential for the staff to have lack of knowledge and not able to respond effectively during an emergency/disaster situation. Findings: During a review of the agency’s emergency preparedness binder on 2/1/2024, at 10:22 a.m., disclosed no documented evidence of an Emergency Preparedness training/disaster drill for all staffs. During an interview on 2/1/2024, at 1:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she could not provide evidence of an Emergency Preparedness/Disaster drill training attended by all HHA staffs. During a review of the agency’s policy and procedure titled, “Emergency Management Plan”, effective date 1/05/2023, indicated annual evaluation and drill to be done annually. The healthcare agency will test the emergency management plan at least annually either in response to an actual emergency or in a planned exercise. All actual responses and exercises will be documented and critique through a multidisciplinary process that includes administrative, clinical and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercise.”

“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 Home Health Agency (HHA) failed to ensure interventions and reassessment for pain were implemented in accordance with the plan of care for four of 7 sampled patients (Patient 1, Patient 3, Patient 4, and Patient 5). This deficient practice has the potential to result in an ineffective pain management leading to an increase and unresolved pain, and discomfort. Findings: a. During a review of Patient 1’s “Patient Information” form indicated a start of care on 11/18/2023, with diagnoses including hypertensive heart disease (high blood pressure), atrial fibrillation (an irregular, rapid heart rate), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 11/18/2023 to 1/16/2024 and 1/17/2024 to 3/16/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for one week and once a week for 8 weeks, to check pain levels using scale (0-10, 0 =no pain, 10=unbearable pain), to check location, intensity and severity of pain, implement pain relief measures and evaluate its effectiveness. The goal included patient will verbalize pain controlled within 2-3/10 (0-10 pain scale) in 2-3 weeks. During a review of Patient 1’s nursing “Clinical Note” dated 12/28/2023, 1/04/2024 and 1/10/2024 indicated Patient 1 were experiencing pain 4/10 to lower back, shoulders, and neck. There were no documented evidence of interventions and reassessment done for the pain. b. During a review of Patient 3’s “Patient Information” form indicated a start of care on 1/03/2024, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose], chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and hypertensive heart disease. During a review of Patient 3’s Home Health Certification and Plan of Care for the certification period starting from 1/03/2024 to 3/02/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for 2 weeks and once a week for 7 weeks, to check pain levels using pain scale 0-10, to check location, intensity and severity of pain, implement pain relief measures and evaluate its effectiveness. The goal included patient will verbalize pain controlled at acceptable level of 1-2/10, demonstrate improve tolerance to activities as evidenced by reduction of weakness/fatigue, improved strength/endurance, by prevented/minimized pain, discomfort with proper medication therapy and non-pharmacological pain management by 3-4 weeks. During a review of Patient 3’s nursing “Clinical Note” dated 1/06/2024, indicated Patient 3 was experiencing pain 5/10 to lower back, right shoulder, and bilateral lower extremity (lower leg). On 1/13/2024 and 1/19/2024, Patient 3 had 4/10 pain to his lower back, right shoulder, and bilateral lower extremity. There were no documented evidence of interventions and reassessment done for the pain. During an interview on 2/01/2024, at 1:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated pain assessment should include pain intervention that was implemented and the effectiveness of the intervention. The DPCS acknowledged in the case for Patient 1, Patient 3, Patient 4, and Patient 5, it was not done. During a review of the agency’s policy and procedure titled, “Pain Assessment”, revised November 2022, indicated each patient will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible: pain intensity using a rating scale (on a scale of 0 – 10: 0=no pain; 10=unbearable pain), pain location, quality, onset, duration, alleviating and aggravating factors, and present pain management regimen and effectiveness. c. During a review of Patient 4’s “Patient Information” form indicated a start of care on 11/14/2023, with diagnoses including hypertensive heart disease (high blood pressure), atrial fibrillation (an irregular, rapid heart rate), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 4’s Home Health Certification and Plan of Care for the certification period starting from 1/12/2024 to 3/14/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for two weeks and once a week for 7 weeks, to check pain levels using scale (0-10, 0 =no pain, 10=unbearable pain), to check location, intensity and severity of pain, implement pain relief measures and evaluate its effectiveness. The goal included patient will verbalize pain controlled within 2-3/10 (0-10 pain scale) in 2-3 weeks. During a review of Patient 4’s nursing “Clinical Note” dated 1/18/2024 and 1/23/2024, indicated Patient 4 were experiencing pain 4/10 to lower back and bilateral knees. There were no documented evidence of interventions and reassessment done for the pain. d. During a review of Patient 5’s “Patient Information” form indicated a start of care on 12/28/2023, with diagnoses including osteoarthritis (occurs when flexible tissue at the ends of bones wears down). During a review of Patient 5’s Home Health Certification and Plan of Care for the certification period starting from 12/28/2023 to 2/25/2024, included an order for the skilled nurse (SN) frequency of visits of once a week for one week, twice a week for two weeks, one a week for six weeks, to check pain levels using scale (0-10, 0 =no pain, 10=unbearable pain), to check location, intensity and severity of pain, implement pain relief measures and evaluate its effectiveness. The goal included patient will verbalize pain controlled within 2-3/10 (0-10 pain scale) in 2-3 weeks. During a review of Patient 5’s nursing “Clinical Note” dated 1/7, 1/15 and 1/23/2024, indicated Patient 5 were experiencing aching pain 4/10 to lower back and bilateral lower extremities. There were no documented evidence of interventions and reassessment done for the pain.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide a written notice of the patient’s bill of rights in a language easily understood (Armenian) to one of seven sampled patients (Patient 1). This failure resulted in a violation of patient’s rights due to patients and representatives not understanding their rights and responsibilities as a patient while under the HHA’s care. Findings: During a review of Patient 1’s “Patient Information” form indicated a start of care on 11/18/2023, with diagnoses including hypertensive heart disease (high blood pressure), atrial fibrillation (an irregular, rapid heart rate), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During the home visit on 1/31/2024, at 11:25 a.m., at Patient 1’s residence it was observed Patient 1 had a binder at the home from the agency. During the review of the contents in the binder/folder disclosed the information regarding patient rights, plan of care, medication list, and information on resources, and literatures were in the English language. During an interview on 1/31/2024, at 11:35 a.m., with Patient 1, Patient 1 stated her preferred language for reading and speaking was Armenian. During an interview on 2/01/2024, at 1:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the agency had a “patient folder” in other languages, including Armenian and did not know why Patient 1 did not have written information in her preferred language. The DPCS stated it was important for the contents in the folder to be in patient’s preferred language so that patients have information in a manner they could understand. During a review of the agency’s undated policy and procedure titled, “Patient Bill of Rights/Responsibilities”, indicated each patient will be an active, informed participant in his/her plan of care. Upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care. The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.”

“Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patient’s continuing need for skilled nursing services for one of seven sample patients. (Patient 4). For Patient 4, who was not homebound or in need of continuous skilled nursing services. This deficient practice resulted in the continuous provision of the home health services lacking the comprehensive assessment to determine the patient’s eligibility to receive the benefits. During a review of Patient 4’s “Patient Information” form indicated a start of care on 11/14/2023, with diagnoses including hypertensive heart disease (high blood pressure), atrial fibrillation (an irregular, rapid heart rate), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 4’s Home Health Certification and Plan of Care for the certification period starting from 11/14/2024 to 1/12/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for two weeks and once a week for 7 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160-millimeter mercury (mmHg) or less than 94 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 55 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 4’s comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 11/14/23, indicated the patient had aching pain on lower back and bilateral knees with the pain level 4 (mild to moderate) on a pain scale from zero (no pain) to ten (worse pain) less than daily. It indicated medication, heat, and rest relieved the pain. During a review of Patient 4’s nursing “Clinical Note” dated 1/18/2024 and 1/23/2024, indicated the patient experienced pain at a level of 4/10 (moderate pain), but there were no documented evidence of interventions and reassessment done for the pain. The patient’s vital signs were within a normal range. Bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for skilled nursing services to continue. On 1/31/24, at 12 p.m., a home visit was made to Patient 4’s residence. Patient 4 was observed alert, oriented and walking on a steady gait without the use of an assistive device. During an interview with Patient 4 on 1/31/24, at 12:30 p.m., he stated that he has pain on his lower back and bilateral knees but the pain medication relieved the pain. During an interview with the Director of Patient Care Services (DPCS) on 2/1/24, at 1:30 p.m., the DPCS stated that she was unable to provide the documentation to justify Patient 4’s need to continue receiving skilled nursing services. A review of the agency’s policy titled” Discharge Criteria and Process” indicated services will be terminated when the goals of home health have been attained or are no longer attainable.”