Immanuel Home Care Services, Inc.

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on clinical record reviews, policy review and staff interview it was determined for 1 of 3 (Pt. #8) clinical records reviewed, wherein the Pt. is receiving wound care, the Agency failed to ensure Physician orders were followed. Findings include: 1. Pt. #8 was admitted for Home Health Services on 8/14/23 with the diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Osteomyelitis, Direct Infection of Right Ankle and Foot in Infection and Parasitic Diseases, Acquired Absence of the Other Left Toe. The clinical record was reviewed on 3/5/24. The record included a POC for the period of 8/14/23 to 10/12/23 requiring, “SN to change central line dressing every week and prn using sterile technique.” The SN visit notes for the week of 8/21/23 to 8/27/23 lacked documentation that the central line was changed. The record also included a PT POC dated 8/24/23 requiring a PT Frequency of “1W1, 2W6.” The record indicated that there were missed PT visits for the weeks of 8/28/23 to 9/3/23, 9/4/23 to 9/10/24 and 9/11/23 to 9/17/23. The record lacked documentation the Physician was notified that the PT visit frequency was not followed. 2. The Agency policy titled, “Clinical Documentation” was reviewed on 3/6/24 and required, “Services not provided and the reason for the missed visits will be documented and reported to the Physician if deemed necessary.” 3. During an interview with the Administrator on 3/6/24 at 1:00 PM, the Administrator stated that the PICC Line should be changed every week using a transparent dressing and documented in the clinical record, and that the Physician should be notified of missed visit.”

“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 review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interviews, it was determined the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies. This was found in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 3/4/24. The folder lacked documentation of the Agency’s transfer and discharge policies. 2. A home visit was conducted at the residence of Pt. #1. SOC 02/25/2 on 3/4/24 at 1:00 PM. During the home visit, the Pt. admission folder was observed, and lacked documentation the Agency had provided Pt. information, regarding the Agency’s policies pertaining to transfer and discharge. 3. The clinical records of the following Pts. were reviewed from 3/4/24 at 12:00 PM to 3/6/24 at 11:00 AM: Pt. #1. SOC 02/25/24. Pt. #2. SOC 01/15/24. Pt. #3. SOC 02/16/24. Pt. #4. SOC 09/14/23. Pt. #5. SOC 01/30/24. Pt. #6. SOC 11/25/20. Pt. #7. SOC 02/17/24. Pt. #8. SOC 08/14/23. Pt. #9. SOC 04/01/23. Pt. #10. SOC 03/09/23. The records lacked documentation the Agency provided Pts. information, regarding the Agency’s policies pertaining to transfer and discharge. 4. During interview with the Administrator on 3/6/24 from 1:45 PM to 3:00 PM, it was confirmed the Pt. admission folder reviewed is used for all Pts. admitted to this Agency, and that the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies.”

“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/or the frequency of visits provided by each discipline. This was found in 8 of 10 (Pts. #1, 2, 3, 4, 5, 7, 9 and 10) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 3/4/24 at 12:00 PM to 3/6/24 at 11:00 AM: Pt. #1. SOC 02/25/24. Pt. received SN, OT, and PT services. Pt. #2. SOC 01/15/24. Pt. received SN, OT, and PT services. Pt. #3. SOC 02/16/24. Pt. received SN, OT, and PT services. Pt. #4. SOC 09/14/23. Pt. received SN, OT, and PT services. Pt. #5. SOC 01/30/24. Pt. received SN services. Pt. #7. SOC 02/17/24. Pt. received SN and PT services. Pt. #9. SOC 04/01/23. Pt. received SN, ST, OT, and PT services. Pt. #10. SOC 03/09/23. Pt. received SN, PT, 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. A home visit was conducted at the residence of Pt. #1. SOC 02/25/2 on 3/4/24 at 1:00 PM. During the home visit, the Pt. admission folder was observed, and lacked documentation the Agency had provided Pt. information, regarding the Agency’s policies pertaining to transfer and discharge. 3. During interview with the Administrator on 3/6/24 from 1:45 PM to 3:30 PM, it was confirmed the Agency failed to specify all disciplines who provide services.”

“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 interviews, 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 6 of 10 (Pts. #2, 3, 4, 5, 9 and 10) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to Home Health Services on 1/15/24 with the primary diagnosis of Polymyalgia Rheumatica. The clinical record was reviewed on 3/6/24. The referral order was faxed to agency on 1/5/24 and included “Home Health Referral”: “home PT.” As of 3/7/24, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #3 was admitted to Home Health Services on 2/16/24 with the primary diagnosis of Multiple Sclerosis. The clinical record was reviewed on 3/5/24. The referral order was faxed to the Agency on 2/8/24 and included “Skilled Nursing, Physical Therapist and Occupational Therapist Referral.” As of 3/7/24, the record lacked documentation the Agency initiated service within the required time frame. 3. Pt. #4 was admitted to Home Health Services on 9/14/23 with the primary diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 3/4/24. The referral order was faxed to the Agency on 9/11/23 and included “Skilled Nursing and Physical Therapy Referral.” As of 3/7/24, the record lacked documentation the Agency initiated service within the required time frame. 4. Pt. #5 was admitted to Home Health Services on 1/30/24 with the primary diagnosis of chronic kidney disease, stage 3 unspecified. The clinical record was reviewed on 3/6/24. The referral order was faxed to the Agency on 1/5/24 and included “Home RN.” As of 3/7/24, the record lacked documentation the Agency initiated service within the required time frame. 5. Pt. #9 was admitted to Home Health Services on 4/1/23 with the primary diagnosis of Malignant Neoplasm of Pancreas. The clinical record was reviewed on 3/4/24. The referral order was written by the Physician on 3/24/23 and included: “Comprehensive nursing assessment/medication, Physical Therapy evaluation and treatment, Speech Therapy evaluation and treatment, Occupational Therapy evaluation and treatment.” As of 3/7/24, the record lacked documentation the Agency initiated service within the required time frame. 6. Pt. #10 was admitted to Home Health Services on 3/9/23 with the primary diagnosis of Pressure ulcer of left buttock, stage 4. The clinical record was reviewed on 3/4/24. The referral order was faxed to Agency on 3/3/23 and included: “Skilled Nursing Referral.” As of 3/7/24, the record lacked documentation the Agency initiated service within the required time frame. 7. During an interview with the Administrator on 3/6/24 from 1:45 PM to 3:30 PM, the Administrator confirmed the initial assessment visits were conducted, after 48 hours of the Face to Face Encounter or referral date.”

“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 reviews, policy review and staff interviews, it was determined that for 1 of 3 (Pt. #8) Pts. reviewed wherein wound care was provided, the Agency failed to ensure Plans of Care included all the requirements. Findings include: 1. Pt. #8 was admitted for Home Health services on 8/14/23 with the diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Osteomyelitis, Direct Infection of Right Ankle and Foot in Infection and Parasitic Diseases, Acquired Absence of the Other Left Toe. The clinical record was reviewed on 3/5/24. The record included a Physician order dated 8/17/23 for “Wound Vac Therapy.” The POC for period of 10/13/23 to 12/11/23 lacked a description of the directions for the application of the wound vac, a description of equipment and supplies used for care, and instructions to Pt. or caregiver regarding care and frequency of application of wound vac therapy. 2. The Agency Policy titled “Plan of Care” was reviewed on 3/6/24 and required, “The Plan of Care shall be completed in full to include: l. Medications, treatments and procedures; m. Medical supplies and equipment required; o. Instructions to patient/caregiver, as applicable.” 3. During an interview with the Administrator on 3/6/24 at 1:00 PM, the above finding was 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 clinical record reviews and staff interviews, it was determined the Agency failed to assess the need for Influenza and Pneumococcal Pneumonia vaccines for 7 of 10 (Pts. # 1,3, 4, 5, 6, 7 and 9) clinical records reviewed. Findings include: 1. The following Pts. were admitted for Home Health Services and their clinical records were reviewed from 3/4/24 to 3/6/24. Pt. #1. SOC 02/25/24. Pt. #3. SOC 02/16/24. Pt. #4. SOC 09/14/23. Pt. #5. SOC 01/30/24. Pt. #6. SOC 11/25/20. Pt. #7. SOC 02/17/24. Pt. #9. SOC 04/01/23. As of 3/7/24, the clinical records reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry, and or dates that the Pt. received the vaccines. 2. During interviews with the Administrator on 3/6/24 between 1:45 PM to 3:30 PM, it was stated that during the SOC visit, 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 findings were confirmed.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record review and staff interviews, it was determined that for 1 of 3 (Pt. #8) clinical record reviewed, wherein wound care was provided, the Agency failed to ensure that the physician was notified regarding a change in Pt. condition. Findings include: 1. Pt. #8 was admitted for home health services on 8/14/23 with the diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Osteomyelitis, Direct Infection of Right Ankle and Foot in Infection and Parasitic Diseases, Acquired Absence of the Other Left Toe. The clinical record was reviewed on 3/5/24. The record included a “Wound Care Worksheet” on 10/16/23 and 10/18/23 that indicated Pt. #8 had a Diabetic ulcer on the left great toe with the onset date of 10/16/23. The SN visit notes lacked documentation the Physician was notified of the new onset of a diabetic ulcer. The clinical record also lacked documentation of any treatment orders for the new wound. The Transfer assessment dated 10/19/23 indicated that Pt. #8 was admitted to the hospital due to “Wound infection or deterioration.” 2. During an interview conducted with the Administrator on 3/6/24 at 1:00 PM, the Administrator stated that the Physician should be notified of any changes in Pt. condition, and the above findings were confirmed.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder and staff interviews, it was determined in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) the Agency failed to provide information regarding the Agency Supervisor (Director of Nursing) and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 3/4/24. The folder lacked information identifying the Agency Supervisor’s name and contact information. 2. The clinical records of the following Pts. were reviewed from 3/4/24 to 3/6/24. Pt. #1. SOC 02/25/24. Pt. #2. SOC 01/15/24. Pt. #3. SOC 02/16/24. Pt. #4. SOC 09/24/23. Pt. #5. SOC 01/30/24. Pt. #6. SOC 11/25/20. Pt. #7. SOC 02/17/24. Pt. #8. SOC 08/14/23. Pt. #9. SOC 04/01/23. Pt. #10. SOC 03/09/23. The clinical records reviewed lacked information identifying the Agency Supervisor’s name and contact information. 3. A home visit was conducted on 3/4/24 at 1:00 PM with Pt. #1. SOC 02/25/24. During the home visit, the Pt. admission folder was reviewed. The folder lacked the name and contact information of the Agency Supervisor. 4. During interview with the Administrator on 3/6/24 from 1:45 PM to 3:30 PM, it was stated the same admission folder is given to all Pts. The Administrator also confirmed the above findings.”

“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 clinical record review, policy review and staff interview, it was determined that for 1 of 3 (Pt. #8) clinical records reviewed, wherein wound care was provided, the Agency failed to ensure the information contained in the clinical record was complete and accurate. Findings include: 1.Pt. #8 was admitted for Home Health Services on 8/14/23 with the diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Osteomyelitis, Direct Infection of Right Ankle and Foot in Infection and Parasitic Diseases, Acquired Absence of the Other Left Toe. The clinical record was reviewed on 3/5/24. The SN Wound Care/Visit notes for the weeks of 8/21/23 to 8/27/23, 8/28/23 to 9/3/23, 9/4/23 to 9/10/23 and 9/11/23 to 9/17/23 lacked documentation of wound measurements. The record indicated that there was an increase in the area of the wound, it measured 3 cm x 1 cm x 1.5 cm on 8/14/23 and then measured 6.3 cm x 4.2 cm x 3 cm when it was measured again on 9/18/23. The SN Wound Care notes dated 10/13/23 contained the following documentation for the section of the note: “Skilled Intervention: SN is greeted by patient… has wound vac in hand and vac is loud and indicating leak. Patient states the machine started making noises about an hour ago… old dressing is removed, dressing is saturated… SN educated patient on staying off foot as much as possible to keep vac in place…patient was seen by wound doctor, new order to hold wound vac and apply wet to dry dressing. Wound treatment complete per MD orders…” The Wound Care notes dated 10/16/23 and 10/18/23 also contained the same/repetitive entries under the same section of the note titled “skilled intervention.” The record contained inaccurate documentation. 2. The Agency policy titled, “Clinical Documentation” was reviewed on 3/6/24 and required, “Purpose: To ensure that there is an accurate record of the services provided, patient response and ongoing need for care.” 3. An interview was conducted was conducted with the Administrator on 3/6/24 at 1:00 PM. The Administrator confirmed that there should have been documentation of weekly wound measurements in the clinical record. During the same interview, the Administrator confirmed that the repeated skilled intervention entries contained in the SN visit notes were inaccurate; and also confirmed the above findings.”

“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 record reviews and staff interview, it was determined the Agency failed to complete a Discharge Summary and ensure a copy of the discharge summary was sent to the Physician. This was found in 3 of 3 (Pts. #9,10 and 8) discharged clinical records reviewed. 3. Pt. #8 was admitted for Home Health Services on 8/14/23 with the diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Osteomyelitis, Direct Infection of Right Ankle and Foot in Infection and Parasitic Diseases, Acquired Absence of the Other Left Toe. The clinical record was reviewed on 3/5/24. The record contained a Transfer assessment indicating that Pt. #6 was transferred to an inpatient facility on 10/19/23. As of 3/6/24, the record lacked documentation that a copy of the Agency’s Discharge/Transfer Summary was sent to the in-patient facility or to the Physician. 4. An interview was conducted with the Administrator on 3/6/24 from 12:45 PM to 3:30 PM. During the interview, the Administrator stated that a copy of the Discharge Summary is only sent to the doctor or the inpatient facility when requested. During the same interview, the above findings were confirmed. Findings include: 1. The clinical record of Pt. #9 was reviewed on 3/5/24. Pt. #9 was admitted to Home Health Services on 4/1/23 with the primary diagnosis of Malignant Neoplasm of Pancreas, unspecified. The record included an OASIS Discharge completed by the RN, dated 8/31/23 documenting that Pt. #9 was discharged from the Agency. As of 3/7/24 the record lacked documentation the Physician was sent a copy of the Discharge Summary. 2. The clinical record of Pt. #10 was reviewed on 3/4/24. Pt. #10 was admitted to Home Health Services on 3/9/23 with the primary diagnosis of Pressure ulcer of left buttock, stage 4. The record included an OASIS Transfer dated 4/6/23 completed by the SN, documenting the Pt. was transferred to an inpatient facility and the Pt. was discharged from the Agency, and admitted to hospital. As of 3/7/24, the record lacked evidence that a Discharge Summary was sent to the physician.”