Aledli Home Healthcare, Inc.

“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 on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure an updated risk assessment was completed utilizing an all-hazards approach. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s undated Emergency Preparedness plan was reviewed on 2/6/24. The plan lacked a facility and community-based risk assessment. 2. During staff interviews with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 12:00 PM, the administrative staff confirmed the above finding.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the Emergency plan policies and procedures were reviewed and updated biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s undated Emergency Preparedness plan was reviewed on 2/6/24. The plan lacked any dates indicating when the Agency had reviewed the plan’s policies and procedures. 2. During staff interviews with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 12:00 PM, The Agency Manager confirmed the above findings.”

“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 the Agency’s Emergency Preparedness Plan and staff interviews, it was determined that the Agency failed to ensure the communication plan was complete. This has the potential to affect all patients served. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 2/6/24. The plan lacked a communication plan that meets the following requirements: Current list of names and contact information for staff members and Patient’s Physicians providing care. 2. During staff interviews with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 12:00 PM, The Agency Manager confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete and accurate.”

“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 9 of 10 (Pts. #1, 2, 4, 5, 6, 7, 8, 9 and 10) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 2/6/24 at 12:00 PM to 2/7/24 at 11:00 AM: Pt. #1. SOC 11/28/23. Pt. received SN, OT, and PT services. Pt. #2. SOC 01/10/24. Pt. received SN, HHA, OT, and PT services. Pt. #4. SOC. 10/31/23 Pt. received SN, PT and ST services. Pt. #5. SOC 12/18/23. Pt. received SN, PT, ST, and OT services. Pt. #6. SOC10/17/23 Pt. received SN, PT, OT, and HHA services. Pt. #7. SOC 08/11/23. Pt. received SN, PT, OT, and ST services. Pt. #8. SOC 06/14/23. Pt. received SN, PT, and OT services. Pt. #9. SOC 06/12/23. Pt. received SN, and PT Pt. #10. SOC 6/23/23. Pt. received SN, and PT 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 2/5/24 at 2:00 PM and 2/7/24 at 1:00 PM. Pt. #1. SOC 11/28/23. Pt. #2. SOC 01/10/24. Pt. #4. SOC 10/31/23. 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 staff interview with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 2:15 PM, it was confirmed the Agency failed to specify all disciplines who provide services.”

“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 4 of 10 (Pts. #4, 8, 9, and 6) clinical records reviewed. Findings include: 1. The following Pts. admitted for skilled home health services, clinical records were reviewed from 2/6/24 at 12:00 PM to 2/7/24 at 11:00 AM: Pt. #4. SOC 10/31/23. Pt. #8. SOC 06/14/23. Pt. #9. SOC 06/12/23. Pt. #6. SOC 10/17/23. As of 2/8/24, the clinical records reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry/assessment. 2. During staff interview with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 2:15 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.”

“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 the Agency failed to provide information regarding the Agency Supervisor (Director of Nursing) and their contact information. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. The Agency Pt. admission folder was reviewed on 2/5/24. The folder lacked information identifying the Agency Supervisor name and contact information. 2. The following clinical records were reviewed from 2/6/24 at 12:00 PM to 2/7/24 at 11:00 AM: Pt. #1. SOC 11/28/23. Pt. #2. SOC 01/10/24. Pt. #3. SOC 01/29/24. Pt. #4. SOC. 10/31/23. Pt. #5. SOC 12/18/23. Pt. #6. SOC 10/17/23. Pt. #7. SOC 08/11/23. Pt. #8. SOC 06/14/23. Pt. #9. SOC 06/12/23 Pt. #10. SOC 6/23/23. The clinical records reviewed lacked information identifying the Agency Supervisor’s name and contact information. 3. The following home visits were conducted from 2/5/24 at 2:00 PM and 2/7/24 at 1:00 PM. Pt. #1. SOC 11/28/23. Pt. #2. SOC 01/10/24. Pt. #3. SOC 01/29/24. Pt. #4. SOC. 10/31/23. 4. During the home visits, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Agency Supervisor. 5. During staff interview with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 1:00 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the RN conducted Home Health Aide onsite supervisory visits every 14 days. This was found in 1 of 2 (Pt. #6) clinical records reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #6 was admitted for Home Health Services on 10/17/23 with the principal diagnosis of Unspecified Combined Systolic and Diastolic Congestive Heart Failure. The clinical record was reviewed on 2/7/24. The record included “Home Health Aide visit record” for services provided to Pt. #6 on 12/23/23, 12/30/23, 1/6/24 and 1/13/24. The record included documentation that supervisory visits were conducted by the Licensed Practical Nurse on 12/27/23 and 1/4/23. The record lacked documentation the RN Case Manager conducted supervisory visits every 14 days for the above-mentioned dates. 2. During an interview with the Agency Manager and Agency Supervisor on 2/7/24 at 1:30 PM, it was stated that the RN Case Manager conducts the Home Health Aide supervisory visits every 14 days, and not the Licensed Practical Nurse. 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 observations and interviews during home visit, review of clinical records, policy review and staff interview, it was determined the Agency failed to ensure the information contained in the clinical records were accurate. This was found in 4 of 10 (Pts. #1, 2, 3 and #4) clinical records reviewed. 4. Pt. #4 was admitted for skilled home health services on 10/31/23 with a Principal Diagnosis of Heart Failure unspecified. A home visit was conducted on 2/5/24 at Assisted Living Facility with the RN. During the visit, an updated list of Pt. #4’s medication was requested from facility. The following medications were listed in the patient’s facility list: Milk of Magnesia 30ml by mouth daily at bedtime as needed, Pramoxine HCL 1% Foam, place 1 applicator rectally every 12 hours as needed for hemorrhoids, Vitamin B-12-tab 1000 mcg oral (by mouth) take one tablet by mouth one time daily. The clinical record was reviewed on 11/29/23 at 11:00 AM. The record contained a “Medication Profile” form completed by RN for the episode of 12/30/23 to 2/27/24. The record “Patient Medication Profile” listed, Pantoprazole 40 mg 1 tablet PO twice daily before meals, Ferrous sulfate 325 mg (65 mg iron) 1 tablet PO twice daily and Acetaminophen 325 mg 2 tablets PO in the morning and 4-6 hrs. PRN. The documentation on the “Patient Medication Profile was not accurate. The record lacked any Physician orders for changes in medications. As of 2/8/24, the Medication Profile was inaccurate. 4. During staff interviews with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 2:15 PM, both confirmed that the clinical records should be accurate and complete, and medications reconciled. Findings include: 1. Pt. #1 was admitted for Home Health Services on 11/28/23 with the principal diagnosis of Nondisplaced Fracture of Shaft of 3rd Metacarpal bone Right Hand. A home visit was conducted on 2/5/24 at 2:30 PM with the Licensed Practical Nurse. During the home visit, Pt#2’s medications were reviewed. The following medication were found at Pt #2’s home: a medication bottle dated 1/24/24 and labeled, Gabapentin 100 mg take 2 capsules oral at bedtime. The Pt. was interviewed and confirmed Pt. was taking 2 tablets of Gabapentin at night. The clinical record was reviewed on 2/5/24 and included the form “Patient Medication Profile” for the episode period of 1/27/24 to 3/26/24. The profile included documentation, “Gabapentin 100 mg 1 capsule per oral nightly.” The medication profile was inaccurate. 2. Pt. #2 was admitted for Home Health Services on 1/10/24 with the principal diagnosis of Hypertensive Heart Disease with Heart Failure. A home visit was conducted on 2/6/24 at 10:15 AM with the Home Health Aide. During the home visit, Pt. #2’s medications were reviewed. The following medications were found at Pt. #2’s home: Furosemide 20 mg and a medication record that lists Furosemide 20 mg - take 1 tablet once a day. During the home visit, the Pt. and caregiver were interviewed and confirmed that the Pt. takes 1 tablet of Furosemide 20 mg once a day. The clinical record was reviewed on 2/6/24 and included the form “Patient Medication Profile” for the episode of 1/10/24 to 3/9/24. The profile included documentation, “Furosemide 20 mg 1 tablet per oral twice daily.” The medication profile was inaccurate. 3. Pt. #3 was admitted for Home Health Services on 1/29/24 with the principal diagnosis of Acute Combined Systolic and Diastolic Congestive Heart Failure. A home visit was conducted on 2/6/24 at 1:10 PM with the Physical Therapist. During the home visit, Pt#3’s medications were reviewed. The Pt. was interviewed and stated that a facility nurse brings the medications for the Pt. to take. During the same visit, the nurse on duty at the facility provided a record titled, “Physician’s Orders” and confirmed that the medications listed on the “Physician’s Order” sheet are Pt. #3’s current medications. The clinical record was reviewed on 2/6/24 and included a form “Patient Medication Profile” for the episode period of 1/29/24 to 3/28/24. The following medications were listed on the facility medication record but not listed on the “Patient Medication Profile:” Aspirin 81 mg chewable - take 1 tablet by mouth once daily, Atorvastatin 40 mg - take 1 tablet by mouth once daily at bedtime, Carvedilol 3.125 mg - take 1 tablet by mouth twice daily with meals, Clopidogrel 75 mg - take 1 tablet by mouth once daily, Docusate sodium 100 mg - take 1 capsule by mouth once daily, Escitalopram 10 mg - take 1 tablet by mouth once daily, Fluticasone 50 mcg/act nasal spray – instill 2 sprays in each nostril once a day, Acetaminophen 500 mg caplet – take 2 tablets (1000 mg) by mouth every 8 hours as needed for pain, Calcium Carbonate 500 mg chewable – take 1 tablet by mouth every 6 hours as needed, Diphenhydramine 25 mg – take 1 tablet by mouth once a day as needed, Senna Laxative 8.6 mg – take 1 table by mouth once daily as needed for constipation. The medication profile was inaccurate.”

“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 review of clinical records 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. #8, 9 and 10) discharged clinical records reviewed. Findings include: 1. The clinical record of Pt. #8 was reviewed on 2/6/24. Pt. #8 was admitted to Home Care services on 6/14/23 with the principal diagnosis of Hypertensive Heart Disease with heart failure. The record included a Discharge Summary completed by the Physical Therapist, dated 8/7/23, documenting that Pt. #8 was discharged from Agency. The record also included an Occupational Therapist Discharge Summary completed by the Occupational Therapist, dated 6/25/23, documenting that Pt. #8 was discharged from the Agency. As of 2/8/24, the record lacked documentation the Physician was sent a copy of the Discharge Summaries. 2. The clinical record of Pt. #9 was reviewed on 2/6/24. Pt. #9 was admitted to Home Care services on 6/12/23 with the principal diagnosis of Essential Primary Hypertension. The record included a Discharge Summary completed by the RN, dated 8/7/23 documenting that Pt. #9 was discharged from the Agency. The record also included a Physical Therapy Discharge Summary completed by the Physical Therapist, dated 8/7/23, documenting that Pt. #9 was discharged from the Agency. As of 2/8/24, the record lacked documentation the Physician was sent a copy of the Discharge Summary. 3. The clinical record of Pt. #10 was reviewed on 2/7/24. Pt. #10 was admitted to Home Care services on 6/23/23 with principal diagnosis of Essential Primary Hypertension. The record included a Physical Therapy Visit note completed by the Physical Therapist, dated 9/11/23, documenting that Pt. #9 was discharged from the Agency. As of 2/8/24, the record lacked evidence that a Discharge Summary was sent to the physician. 4. During staff interviews with the Agency Manager (Administrator) and Agency Supervisor (Director of Nursing) on 2/7/24 at 2:15 PM, both confirmed that Agency staff failed to send discharge summary to the physician.”