Accucare Physical Therapy and Rehabilitation Services

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based of review of Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Plan was established based on a risk assessment using an all hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 04/17/24 at 11:45 AM. The plan lacked documentation that a facility-based and/or community based risk assessment was completed for 2021, 2022 and 2023. 2. During an interview with the Director of Nursing on 04/17/24 at 3:30 PM, the Director of Nursing confirmed the above findings.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on the clinical records review, policy review and Staff interview, it was determined in 5 of 7 (Pts. #3, 5, 2, 4 and 7) records reviewed, the clinical records were not completed as required. 3.Pt. #2 was admitted to Home Health Services on 03/07/24 with the Diagnosis of: Alzheimer’s Disease Unspecified. The clinical record was reviewed on 04/16/24. The clinical record included an incomplete “Service Agreement, Consent and Authorization” form. The form lacked the information for the advance directives. 4. Pt. #4 was admitted to Home Health Services on 03/07/24 with the Diagnosis of: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 04/16/24. The clinical record included an incomplete “Service Agreement, Consent and Authorization” form. The form lacked the information for the advance directives. 5. Pt. #7 was admitted to Home Health Services on 06/08/23 with the Diagnosis of: Alzheimer’s Disease Unspecified. The clinical record was reviewed on 04/16/24. The clinical record included an incomplete “Service Agreement, Consent and Authorization” form. The form lacked the information for the advance directives and lacked the date of the patient signature. The clinical record also lacked the specific information regarding the summary of patient care. 6. The Agency’s Policy titled “Entries into the Clinical Record” was reviewed on 04/17/24 at 1:00 PM. The policy included “…PROCEDURE 1. A clinical record…will include at a minimum: A. Patient consent, authorization, and election forms, as applicable …E. Dates, times and types of interventions, assessments, and coordination of care… 3. Entries into the clinical record will be clear, concise and specific statements of fact…” 7.The findings were confirmed with the Administrator and Director of Nursing, on 04/17/24 between 10:00 AM and 2:30 PM. Findings include: 1. Pt. # 3 was admitted to Home Health Services on 04/11/24 with Diagnosis of Hypothyroidism. The clinical record was reviewed on 04/16/24. The Service Agreement, Consent and Authorization form dated 04/11/24 at the start of care and signed by Pt. #3 and admitting Nurse, lacked information on Advanced directives. 2. Pt. #5 was admitted to Home Health Services on 02/23/24 with Diagnosis of Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 04/16/24. The Service Agreement, Consent and Authorization form dated 02/23/24 at the start of care and signed by Pt. #5 and admitting Nurse, lacked information on Advanced directives.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide 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 to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on the review of the admission packet, home visit observations, and staff interview, it was determined in 3 of 7 (Pts.#1, 2 and 3) clinical records reviewed, the Agency failed to provide patients the Agency’s transfer and discharge policies. Findings include: 1. The Admission packet was reviewed on 04/16/24 and lacked the Agency’s transfer and discharge policies. 2. It was observed during the home visits, conducted on 04/16/24 and 04/17/24, the home folders lacked the transfer and discharge policies for: Pt #1 SOC:11/02/23. Pt #2 SOC: 03/07/24. Pt #3 SOC: 04/11/24. 3. The findings were confirmed, during the interviews with the Administrator and Director of Nursing, on 04/18/24 between 12:00 PM and 12:30 PM.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 4 of 7 (Pts. # 2, 1, 3 and 6) clinical records reviewed the Agency failed to provide the care as ordered by the physician. 2. Pt. #1 was admitted to Home Health Services on 11/02/23 with Diagnosis of Hemiplegia following other cerebrovascular disease affecting left nondominant side. The clinical record was reviewed on 04/16/24 and 04/17/24. The POC effective 03/01/24 included the following medications: “….Fluorouracil cream….Amlodipine….Atorvastatin....Vitamin B12 500 mcg….Vitamin D3…. Lansoprazole….Aspirin 325 mg…. Stool Softener….”. A home visit was conducted with the Director of Nursing/Registered Nurse on 04/17/24 at 8:00 AM and the following medications were observed in Pt. #1’s home: 1 bottle of Vitamin C 1000 mg, 1 bottle Aspirin 81 mg, 1 bottle Vitamin B12 1000 mcg and 1 bottle of Dry Eye relief eye drops. During interview with Pt. #1’s caregiver on 04/17/24 at 8:30 AM, it was stated that Pt. #1 uses the medications listed above. The medications observed were not listed as ordered by the physician. 3. Pt. # 3 was admitted to Home Health Services on 04/11/24 with Diagnosis of Hypothyroidism. The clinical record was reviewed on 04/16/24. The POC effective 04/11/24 included the following medications: “….Bupropion….Brexpriazole….Clindamycin….Cyclobenzaprine Hydrochloride….Diazepam….Voltaren….Duloxetine….Frova….Lamotrigine….Levothyroxine….”. A home visit was conducted with the Director of Nursing/Registered Nurse on 04/17/24 at 1:00 PM and the following medications were observed in Pt.# 3’s home: 1 bottle of Propanolol….1 bottle of Ondansetron… 1 bottle of Aspirin….1 bottle of Vitamin C….1 bottle of Topiramate….1 bottle of Vitamin D3….1 bottle of Potassium Citrate….1 bottle of Magnesium….1 bottle of Multivitamins….1 bottle of Lecithin…1 bottle of Morphine Sulfate….and 1 Naloxone nasal spray. During interview with Pt. #3 on 04/17/24 at 1:30 PM, it was stated that he has been taking these medications. The medications observed were not listed as ordered by the physician. 4. Pt. #6 was admitted to Home Health Services on 02/27/24 with Diagnosis of Pressure ulcer sacral region stage 2, Atherosclerosis Native Arteries of right leg with Ulcer and Pressure ulcer of the site, stage 1. The clinical record was reviewed on 04/16/24 and 04/17/24. The SOC assessment dated 2/27/24, indicated stage 2 sacrum pressure ulcer, right foot arterial ulcer and right knee stage 1 pressure ulcer. The POC effective 02/27/24, indicated: “….Medications….Silver Sulfadiazine ext cream tube 1 2 x a day topical….orders for discipline and treatment….SN to perform pressure ulcer care to sacrum. Cleanse/irrigate wound with saline solution, apply alginate/duoderm, cover and secure with bandage….” The SN notes dated 03/01/24, 03/05/24, 03/08/24 and 03/13/24, contained documentation: “Integumentary…. Comment….2 inches diameter arterial ulcer ball right foot; skin warm and moist; maxsorb alginate/duoderm dressing to sacrum; Optifoam gentle silicone bordered foam; Puracol plus fenestrated wound dressing around edges; gauze around edges to avoid leakage of secretions. Right knee stage 1 ulcer treat with Silver Sulfadiazine…” The SN was not following wound care interventions as ordered by the physician. 5. During interviews with the Administrator and Director of Nursing on 04/17/24 from 10:00 AM to 11:00 AM and with Director of Nursing on 04/17/24 at 2:30 PM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. #2 was admitted to Home Health Services on 03/07/24 with the Diagnosis of: Alzheimer’s Disease Unspecified. The clinical record was reviewed on 04/16/24. The POC dated 03/07/24, included SN orders to assess the patient 1 time a week for 9 weeks. The SN failed to assess the patient during the week of 03/17/24 (week #3).”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on the onsite observations and staff interview, it was determined the Agency failed to ensure the Administrator maintained responsibility for all day-to-day operations. Findings include: 1. Surveyor arrived at Agency on 04/16/24 at 9:00 AM. It was observed no one was at the Agency. Several calls were made to the Agency between 9:00 AM and 9:40 AM, with no answer and no ability to leave a message. Agency staff arrived at 9:40 AM. The Administrator arrived after 11:00 AM. The Administrator failed to maintain the Agency’s documented operating hours of 9:00 AM through 5:00 PM Monday to Friday. 2. The findings were confirmed with the Administrator and Director of Nursing, on on 04/18/24 between 12:00 PM and 12:30 PM.”