Apex Home Healthcare

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure that patients were informed of the services and frequencies to be provided on admission and to participate in the development of the plan of care (POC) for three patients out of seven home visits conducted. (Patients #3, #6 & #7) The findings include: A review of the admission consent form for Patient #3 revealed documentation for services to be provided. The consent did not document the frequency of nursing or physical therapy services. The medical record revealed no additional evidence that the patient was consulted and consented to planned services and care both initially or to date. A review of the admission consent form for Patient #6 revealed documentation for services to be provided. The consent did not document the frequency of nursing or physical therapy services. The medical record revealed no additional evidence that the patient was consulted and consented to planned services and care both initially or to date. A review of the admission consent form for Patient #7 revealed documentation for services to be provided. The consent form did not document the frequency of occupational therapy services. The medical record revealed no additional evidence that the patient was consulted and consented to planned services and care both initially or to date. During an interview with the Executive Director on 8/22/2024 at 3:00 PM, she confirmed that the clinicians did not complete the consent for Patients 3, 6, and 7. .”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to provide a written visit schedule for each discipline providing services for six patients out of seven sampled during home care visits. (Patients #1, #3, #4, #5, #6, and #7) The findings include: A home care observation on 8/20/24 at approximately 3:00 PM with Staff C, Occupational Therapy Assistant (OTA) for Patient #1, revealed no calendars for the discipline visits. Patient #1 was interviewed on 8/20/24 at 3:10 PM who said she gets a call from staff when they are coming. Staff C confirmed that she usually calls the night before or the day of the visit. A home care observation on 8/21/24 at 9:00 AM for Patient #3 with Staff B, Occupational Therapist, revealed no calendars for the discipline visits. Patient #3 was interviewed on 8/21/24 at 9:00 AM who said he gets a call sometimes the night before or when they are on their way. Staff B confirmed that she usually calls the night before or the day of the visit. A home care observation on 8/21/24 at 10:00 AM for Patient #4 with Staff A, Registered Nurse, revealed no calendars for the discipline visits. Patient #4 was interviewed on 8/21/24 at 10:15 AM who said they sometimes call the night before or when they are coming. Staff A confirmed that he usually calls the night before. “We do not have visit calendars to leave in the home.” A home care observation on 8/21/24 at 12:00 PM for Patient #5 with Staff D, Physical Therapy Assistant, revealed no calendars for the discipline visits. Patient #5’s spouse was interviewed on 8/21/24 at 12:15 PM who said that the staff usually calls them the night before a visit. “Sometimes they will tell me when they will be back before they leave.” A home care observation on 8/21/24 at 2:00 PM for Patient #6 with Staff E, Physical Therapist, revealed no calendars for the discipline visits. Patient #6 was interviewed on 8/21/24 at 2:15 PM who said they sometimes call the night before or when they are coming. Staff E confirmed that she would try to contact her the night before. A home care observation on 8/21/24 at 11:30 AM for Patient # 7 with Staff F, Licensed Practical Nurse, revealed no calendars for the discipline visits. Patient #7 ‘s spouse was interviewed on 8/21/24 at 11:30 AM who said they sometimes call the night before or when they are coming. Staff F confirmed that she would try to contact her the night before. During an interview on 8/21/24 at 4:00 PM, the Executive Director said the patients should be involved in deciding when and on what days the visits are made.”