A-Cure Healthcare Solutions, Inc.

“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 4 of 7 (Pts. #2, 3, 5 and 6) records reviewed, the clinical records were not completed as required. 3. Patient #5 was admitted to the Home Health Services on 03/09/24 with the Diagnosis of: Unspecified Severe Protein-Calorie Malnutrition. The clinical record was reviewed on 04/23/24. The clinical record included an incomplete “Flu/Pneumonia Vaccine Checklist” form. The form lacked the information regarding the patient’s responses. The record also included late entries for the Physical therapy visit notes dated 04/02/24, 04/08/24 and 04/16/24 (which were submitted 04/24/24). 4. Patient #6 was admitted to the Home Health Services on 01/01/24 with the Diagnosis of: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Unspecified. The discharged clinical record was reviewed on 04/23/24 The discharged clinical record included an incomplete “Flu/Pneumonia Vaccine Checklist” form. The form lacked the information regarding the patient’s responses. The record also included late entries for the Physical therapy visit notes dated 04/04/24, and 04/11/24 (which were submitted 04/24/24). 5. Patient #7 was admitted to the Home Health Services on 02/21/23 with the Diagnosis of: Complex Regional Pain Syndrome Right Lower Limb. The discharged clinical record was reviewed on 04/23/24. The discharged clinical record lacked the Physical therapy missed visit notes dated for May 2023. During the interview with the Clinical Supervisor on 04/24/23 at 10:50 AM, it was stated that the notes were in “Therapy Boss” and he will have them incorporated into the Agency’s electronic records. 6. The Agency’s Policy titled “Timely Submission of Patient Documentation” was reviewed on 04/24/24 at 12:30 PM. The policy included “…PROCEDURE … 2. Itineraries, with all visit reports attached, must be submitted the following week or seven (7) business days…from the date of the visit. The discharge medical record is complete within 45 days of discharge.” 7.The findings were confirmed, during the interviews with the Clinical Supervisor and Administrator, on 04/24/24 between 10:00 AM and 11:30 AM. 1. Pt. #2 was admitted to Home Health Services on 03/21/24 with the primary Diagnosis of Non-ST elevation (NSTEMI) myocardial infarction. The clinical record was reviewed on 04/22/24. The record included “Flu/Pneumonia Vaccine Checklist” which was incomplete. The form lacked the information regarding the patient’s responses. 2. Pt. #3 was admitted to Home Health Services on 03/15/24 with the primary Diagnosis of Encounter for removal of surgical wound dressing. The clinical record was reviewed on 04/23/24. The clinical record included “Flu/Pneumonia Vaccine Checklist” which was incomplete. The form lacked the information regarding the patient’s responses.”

“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 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. 1. The Agency Pt. admission folder was reviewed on 04/22/24. The folder lacked information identifying the Clinical Manager’s name and contact information. 2. The clinical records of the following Pts. were reviewed from 4/22/24 to 4/23/24: Pt. #1. SOC 01/21/24. Pt. #2. SOC 03/21/24. Pt. #3. SOC 03/15/24. Pt. #4. SOC 03/26/24. Pt. #5. SOC 03/09/24. Pt. #6. SOC 10/12/23. Pt. #7. SOC 02/21/23. The clinical records reviewed lacked information identifying the Clinical Manager’s name and contact information. 3. The following home visits were conducted on 04/23/24 from 9:00 AM to 3:30 PM. Pt. #1. SOC 01/21/24. Pt. #2. SOC 03/21/24. Pt. #3. SOC 03/15/24. 4. During the home visits, on 04/23/24 from 9:00 AM to 2:30 PM, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Clinical Manager. 5. During staff interview with the Administrator and Clinical Supervisor on 04/25/24 at 12:00 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.”