Atrium Healthcare Services, LLC

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical records review, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide information regarding the Administrator. Findings include: 1. The Pt. admission folder was reviewed on 4/22/24. The folder lacked documentation identifying the Administrator’s name, and information for contacting the Administrator. 2. The following home visits were conducted on 4/22/24 and 4/23/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. During the home visits, the Pt. admission folders were observed, and lacked the Administrator’s name, and information for contacting the Administrator. 3. The following clinical records were reviewed on 2/23/24 and 2/24/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. Pt. #4. SOC 1/27/24. Pt. #5. SOC 3/8/24. Pt. #6. SOC 2/8/24. Pt. #7. SOC 12/28/23. The records lacked documentation the Agency had provided the Administrator’s name, and information for contacting the Administrator. 4. During an interview with the Director of Nursing on 4/24/24 from 10:22 AM to 1:06PM, the Director of Nursing confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide information regarding the Administrator.”

“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 a review of the Agency’s Pt. admission folder, observation during home visits, clinical records review, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline. Findings: 1. The Pt. admission folder was reviewed on 4/22/24 and contained the form titled, “IN-HOME CALENDAR”. The Agency required each discipline to enter their name and the frequency of visits on the form. 2. Home visits were conducted on the following Pts. on 4/22/24 and 4/23/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. During the home visits, the Pt. admission folders were observed, and lacked documentation that staff included the visit frequency for each discipline providing service. 3. The following clinical records were reviewed on 4/23/24 and 4/24/24: Pt. #1. SOC 1/27/24. Pt. #2. SOC 12/23/23. Pt. #3. SOC 3/15/24. Pt. #4. SOC 1/27/24. Pt. #5. SOC 3/8/24. Pt. #6. SOC 2/8/24. Pt. #7. SOC 12/28/23. The records lacked documentation the Agency had provided in writing, the visit frequency for each discipline providing service. 4. During interviews with the Director of Nursing on 4/24/24 between 10:22 AM and 1:06 PM, the Director confirmed the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation and interviews during a home visit, clinical record review and staff interviews, it was determined that for 1 of 3 Pts. (Pt. #3) receiving Physical Therapy services, the Agency failed to ensure that the PsOC included all the equipment. Findings include: 1. Pt. #3 was admitted on 3/15/24 for home health services with the diagnoses of, but not limited to Muscle Weakness, Difficulty in Walking and Osteoarthritis of Knee, Unspecified. A home visit was conducted with E#2 (Physical Therapist) on 4/23/24 at 11:00 AM. During the visit, Pt. #3 was wearing bilateral knee braces, and these were removed by E#2 while providing therapy exercises for Pt. #3. E#2 stated that the bilateral knee braces were supplied as requested by the Physician and is being continuously used by Pt. #3 as support for transferring and walking. Pt. #3 was interviewed during the home visit and stated that the braces are used all the time “they support my knees.” Pt. #3’s clinical record was reviewed on 4/24/24. The initial POC effective 3/15/24, and the Physical Therapy POC dated 3/15/24 lacked documentation for the use of the bilateral knee braces, and interventions for its use. 2. During an interview conducted with the Director of Nursing on 4/24/24 at 12:00 PM, the above findings were confirmed.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical records review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge/Transfer Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6 was admitted for home health services on 12/28/23 with a primary diagnosis of Type 2 Diabetes Mellitus with unspecified complications. The record contained a transfer assessment, indicating that Pt. #6 was transferred to an in-patient facility on 1/9/24. As of 4/23/24, the record lacked documentation that a copy of Pt. #6’s transfer summary was sent to the Physician. 2. Pt. #7 was admitted for home health services on 2/28/24 with a primary diagnosis of Acute Systolic (Congestive) Heart Failure. The record contained a discharge assessment dated 4/1/24, indicating that Pt. #7 was discharged from the Agency. As of 4/24/24, the record lacked documentation that a copy of Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Director of Nursing on 4/24/24 at 12:00 PM, the above findings were confirmed.”