Wellspring Healthcare Services, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to have a communication plan that included an accurate list of required names and contact information. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/27/23. The plan lacked a communication plan that meets the following requirements: Current list of names and contact information for staff members and entities providing service under contract, and Patient’s Physicians providing care. 2. During an interview with the Administrator, on 11/29/23 at 1:00 PM, the Administrator confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete and accurate.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan, In-services Binder, and staff interview, it was determined the Agency failed to conduct staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Disaster Plan and In-services Binder were reviewed on 11/27/23. The In-services Binder lacked documentation that the Agency conducted Emergency preparedness staff training in 2021 and 2022. 2. During interview with the Administrator, on 11/29/23 at 12:45 PM, the Administrator confirmed the above findings.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on clinical record reviews, infection control binder, Agency policy review and staff interviews, it was determined the Agency failed to ensure that the Agency’s infection control surveillance plan was complete and accurate by failing to integrate all data, tracking and monitoring for 2 of 2 Pts. (Pts. #1 and #7) reviewed who were receiving antibiotics. Findings include: 1. Pt. #1 was admitted for skilled home health services with a Principal Diagnosis of Disruption of External Operation (surgical) Wound on 1/24/23. The clinical record reviewed included documentation of the following physician orders: Levofloxacin 500 mg 1 tablet every 24 hours (date filled 7/3/23), Doxycycline Hyclate 100 mg 1 tablet twice daily (date filled 7/3/23), Doxycycline Hyclate 100 mg 1 tablet twice daily (11/17/23). The infection control log lacked documentation of an infection report for the above-mentioned dates for Pt. #1. 2. Pt. # 7 was admitted for skilled home health services with a Principal Diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record reviewed included documentation on the SN notes dated 10/20/23 that Pt. #7 received “Amoxicillin 500 mg 1 tablet every 12 hours for 7 days (oral) due to mouth abscess.” The infection control log lacked documentation of an infection report for Pt. #7. 3. The document “Infection Control Log Report Year 2023” was reviewed and lacked documentation of the above-mentioned dates for Pts. #1 and #7. 4. The Agency’s policy titled, “Infection Control Surveillance” dated 4/23/20 was reviewed and required, “(The Agency) will establish a continuous date monitoring and collecting system to detect infections of identify changes in infection trends… (The Agency) will implement a process of identifying all infections in the patient…population …and evaluate the effectiveness of current control measures or identify an action plan to improve incidents of infections…The Agency will perform targeted infection control surveillance as follows…Patient infections to be reported while the patient is receiving services form the Agency: wound infections that develop thirty days or greater after the admission that require antibiotic treatment or are identified by lab test…When pattern or trend in infections is identified m the agency will investigate where the patients…may have acquired the infections…An infection control log will be maintained. Information will be integrated into orientation in-services and quality improvement program…” 5. During an interview with the Director of Nursing on 11/30/23 at 9:30 AM, it was stated that the Agency’s Infection Control Surveillance policy requires that all Pts. with infections or using antibiotics should be reported by the nurse to the RN case manager, integrated in the infection surveillance report and analyzed. During the same interview, the findings were confirmed.”

“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 review of the Agency’s Admission Folder, and staff interviews, it was determined the Agency failed to ensure Pts. received a copy of the Agency’s transfer and discharge policy. This has the potential to affect all patients admitted to the Agency. Findings include: 1. The Agency’s Admission Folder provided to the patients, was reviewed on 11/27/23 at 9:50 AM. The folder lacked a copy of the Agency’s transfer and discharge policy. 2. During interview with the Administrator on 11/29/23 at 1:00 PM, the Administrator indicated the same folder is given to all Pts. and, confirmed the admission folder did not include a copy of the Agency’s transfer and discharge policy.”

“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 review of clinical records, observation during home visits, and staff interviews, it was determined that the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from11/27/23 at 1:30 PM to 11/29/23 at 11:30 AM: Pt. #1. SOC 01/24/23. Pt. received SN and PT services. Pt. #2. SOC 08/29/23. Pt. received SN services. Pt. #3. SOC 10/11/23. Pt. received PT services. Pt. #4. SOC. 11/01/23 Pt. received SN, PT and OT services. Pt. #5. SOC 05/22/23. Pt. received SN and OT services. Pt. #6. SOC 06/28/23 Pt. received SN, PT, OT and HHA services. Pt. #7. SOC 08/11/23. Pt. received SN, PT, OT and MSW services. The records lacked documentation that the Pt. or legal guardian was notified in writing of the services to be provided and the frequency. 2. The following home visits were conducted from 11/27/23 at 2:30 PM and 11/28/23 at 10:30 AM and 11:00 AM. Pt. #1. SOC 01/24/23. Pt. #2. SOC 08/29/23. Pt. #3. SOC 10/11/23. During the home visits, the patient’s admission folder was observed and lacked documentation of the services provided, and the frequency of the visits. 3. During interview with the Administrator on 11/29/23 at 1:00 PM, the Administrator confirmed the Agency does not inform Pts. in writing of the frequency of visits and failed to specify all disciplines who provide service.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record reviews and staff interview, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. This was found in 4 of 7 (Pts. # 2, 3, 4 and 5) clinical records reviewed. 4. Pt. #6 was admitted for skilled home health on 5/22/23 with a Principal Diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 11/28/23. The record contained a referral form which indicated that the Pt. was discharged from an inpatient facility on 5/18/23. The SOC initial comprehensive assessment was conducted by the RN on 5/22/23. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 5. During an interview with the Director of Nursing on 11/29/23 at 12:00 PM it was stated that the initial assessment should be conducted within 48 hours of the referral date. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to Home Health Services on 8/29/23 with the primary diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/27/23. The Face-to Face form signed by the Physician on 8/8/23 required: “SN to assess, teach and visit patient.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/30/23, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #3 was admitted to Home Health Services on 10/11/23 with the primary diagnosis of Unilateral Primary Osteoarthritis, Right Knee. The clinical record was reviewed on 11/29/23. The Face to Face form signed by the Physician on 10/9/23 required: “PT services.” The record lacked a Physician order SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/30/23, the record lacked documentation the Agency initiated service within the required time frame. 3. Pt. #4 was admitted to Home Health Services on11/1/23 with the primary diagnosis of “Unspecified Fracture of Upper end of Right Humerus, Subsequent Encounter for Fracture with Routine Healing.” The clinical record was reviewed on 11/29/23. Pt. was discharged from SN facility on 10/29/23 with home health services for PT, OT, and RN.” The record lacked a Physician ordered SOC date. As of 11/30/23, the record lacked documentation the Agency initiated service within the required time frame.”

“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 clinical record review and staff interviews, it was determined that the Agency failed to ensure Plans of Care included all the requirements. This was found in 2 of 7 (Pts. #5 and 6) clinical records reviewed. Findings include: 1. Pt. #5 was admitted to home health on 5/22/23 with a Principal Diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease. The clinical record was reviewed on 11/29/23. The record included documentation on the SN note that Pt. #5 had abrasions on right and left shin area, and treatments were provided from 10/11/23 to 11/15/23. The POC for the period of 11/18/23 to 1/16/24 lacked documentation of description of the procedure and frequency of the treatment and equipment for wound care. 2. Pt. #6 was admitted to home health on 6/28/23 with a Principal Diagnosis of Chronic Atrial Fibrillation and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/29/23. The POC for the certification period of 8/27/23 to 10/25/23 lacked documentation of parameters for reporting the weight changes to the physician. 3. During an interview with the Director of Nursing on 11/29/23 at 11:30 AM, it was stated that it is Agency Policy for those Pts. with heart failure, that weekly weight is being taken, monitored and reported to the physician if outside of the range (more than 3-5 pounds in a week). The Director of Nursing also confirmed that there should have been weight parameters on the POC. During the same interview, the above findings were confirmed.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on review of clinical records, policy review and staff interviews, it was determined the Agency failed to assess the need for Influenza and Pneumococcal Pneumonia vaccines for 6 of 7 (Pts. #1, 2, 3, 4, 5 and 7) clinical records reviewed. Findings include: 1. The following Pts. admitted for skilled home health services, clinical records were reviewed from 11/27/23 at 1:30 PM to 11/29/23 at 11:30 AM: Pt. #1. SOC 01/24/23. Pt. #2. SOC 08/29/23. Pt. #3. SOC 10/11/23. Pt. #4. SOC 11/01/23. Pt. #5. SOC 05/22/23. Pt. #7. SOC 08/11/23. As of 11/30/23, the clinical records reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry/assessment. 2. During an interview with the Director of Nursing on 11/29/23 at 12:15 PM, it was stated that during the start of care, the patient’s Influenza and Pneumococcal vaccination status is assessed, and this information is documented in the clinical record. During the same interview, the above finding was confirmed.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observation and interviews during home visits, review of clinical records and staff interview, it was determined the Agency failed to ensure that documentation in the clinical record was accurate and complete. This was found in 3 of 7 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 2. Pt. #2 was admitted to Home Health Services on 8/29/23 with the primary diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/27/23. Pt. #2’s Medication Profile and medications were reviewed with Pt. during home visit on 11/27/23. Pt. #1’s Medication Profile was not updated to include Januvia, and Bisoprolol Fumarate. Pt #2 provided a bottle of Januvia 100 mg tablets and a bottle of Bisoprolol Fumarate 5mg, Pt. stated she takes a pill of each medication daily. The medication Profile included Glucotrol XL 5mg oral tablet, one tablet daily by mouth, Potassium Chloride 20 MEQ oral tablet, one tablet daily by mouth and Budesonide Formoterol 160 mcg-4.5 mcg 2 puffs every six hours as needed for SOB (shortness of breath) wheezing, inhaled (INH). Pt. confirmed she is no longer taking the last three medications. The record lacked any Physician orders for changes in medications. As of 11/27/23, the Medication Profile was inaccurate. 3. Pt. #3 was admitted to Home Health Services on 10/11/23 with the primary diagnosis of Unilateral Primary Osteoarthritis, Right Knee. The clinical record was reviewed on 11/28/23. Pt. #3’s Medication Profile and medications were reviewed with Pt. during home visit on 11/28/23. Pt. #3’s Medication Profile was not updated to include Amlodipine Besylate 100 mg OD, Fluoxetine 20 mg capsules OD and Atorvastatin 20 mg tablets OD. Pt. #2 confirmed she is taking the above medications. The record lacked any Physician orders for changes in medications. As of 11/28/23, the Medication Profile was inaccurate. 4. During an interview conducted with the (DON) Director of Nursing on 11/30/23 at 1:00 PM, the DON confirmed that the clinical records should be accurate and complete, and medications reconciled. Findings include: 1. Pt. #1 was admitted for skilled home health services on 1/24/23 with a Principal Diagnosis of Disruption of External Operation (surgical) Wound. A home visit was conducted on 11/28/23 at 10:30 AM with the RN. During the home visit, an interview was conducted with the Pt. and the patient’s medications were reviewed. The following medications were found at the patient’s home: Ferrous Sulfate 325 mg 1 tablet oral once daily, Aspirin 81 mg 1 tablet oral once daily, Centrum Silver Multivitamins, Clopidogrel 75 mg 1 tablet oral every PM and Vitamin C 500 mg 1 tablet once daily. Pt. #2 stated, “I take (the above-mentioned) medications, but I don’t take Apixaban since I use the Clopidogrel as anticoagulant...” The clinical record was reviewed on 11/29/23 at 11:00 AM. The record contained a “Medication Profile” form completed by the RN for the episode of 11/20/23 to 1/18/24. The record “Medication Profile” listed the following: Apixaban 2.5 mg oral twice per day by mouth.” The documentation on the “Medication Profile” was not accurate.”