Senior Care at Home, Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined in 73 of 95 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 10/1/23 to 11/22/24, was reviewed on 12/5/24 at 9:30 AM. The report included error # -3330 for 73 of 95 late submissions, 76.84% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and the Nursing Supervisor on 12/4/24 at 12:00 PM, it was confirmed that the error occurred.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined that in 2 of 7 (Pts. #1 and 2) clinical records reviewed, the Agency failed to ensure the Physician reviewed and signed the initial POC, as required by the Agency. Findings include: 1. Pt. #1 was admitted to home health services on 10/30/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 12/3/24. The clinical record included the initial POC dated 10/30/24. As of 12/3/24, the POC lacked the Physician’s signature, which confirms the Physician reviewed and approved the POC. 2. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the initial POC dated 10/25/24. As of 12/3/24, the POC lacked the Physician’s signature, which confirms the Physician reviewed and approved the POC. 3. The Agency policy titled; “Medical Supervision” was reviewed on 12/5/24. The policy included, “…2. A Plan of Care is developed for each client at the time of admission and signed by the physician/allowed non-physician (NPP) within an appropriate time frame…” 4. During staff interviews with the Administrator and Nursing Supervisor on 12/4/24 at 2:45 PM, the Nursing Supervisor stated the Agency require the POC to be reviewed, and signed by the Physician within 30 days of the effective date of the POC. During the same interview, both confirmed the above findings.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined in 1 of 1 (Pt. #7) clinical record reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure that written Pt. care instructions were provided to the Home Health Aide. Findings include: 1. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included Home Health Aide visit notes, 2 times a week from 11/23/22 to 2/9/23 that contained documentation the Home Health Aide provided personal care. The last “HHA (Home Health Aide) Care Plan” completed by the RN providing instructions to the Aide was dated “7/22/2022 - 9/19/2022”. The record lacked a Care Plan for the Home Health Aide to provide personal care from 11/23/22 to 2/9/23. 2. The Agency’s policy titled; “Home Health Aide: Assignment” was reviewed on 12/5/24. The policy required, “…Purpose… To provide direction and supervision of care provided by Home Health Aides…” 3. During staff interviews with the Administrator and Nursing Supervisor on 12/4/24 at 2:45 PM, the Administrator stated the RN is required to review and update the HHA Care Plan “every 60 days”. During the same interview, both confirmed the above findings.”

“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 and interview during home visits, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 12/2/24. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 12/2/24 and 12/3/24: Pt. #1. SOC 10/30/24. Pt. #2. SOC 10/25/24. Pt. #3. SOC 9/27/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed from 12/2/24 and 12/4/24: Pt. #1. SOC 10/30/24. Pt. #2. SOC 10/25/24. Pt. #3. SOC 9/27/24. Pt. #4. SOC 10/23/24. Pt. #5. SOC 8/23/24. Pt. #6. SOC 3/4/24. Pt. #7. SOC 3/24/22. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During staff interviews with the Administrator and Nursing Supervisor on 12/4/23 at 11:30 AM and 2:45 PM, both confirmed the Agency failed to provide the Pt./patient’s representative with the Administrator’s name and contact information.”

“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 a review of clinical records, Agency policy, and staff interviews, it was determined in 5 of 7 (Pts. #1, 2, 7, 3, and 6) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 4. Pt. #3 was admitted to home health services on 9/27/24 with a diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease. The clinical record was reviewed on 12/3/24. The clinical record contained a Face-to-Face Document with the service date of 8/12/24, which was faxed to the Agency on 9/4/24 with orders for SN and PT services. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician ordered SOC date. 5. Pt. #6 was admitted to home health services on 3/9/24 with a diagnosis of Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 12/3/24. The clinical record contained a referral from an in-patient facility with an order date of 2/26/24 for home health services and was faxed to the Agency on 2/28/24. The clinical record lacked an RN initial comprehensive assessment with 48 hours of the referral, or a Physician ordered SOC date. 6. The Agency Policy titled “Medical Supervision” was reviewed on 12/5/24 and required, “Special Instructions: Physician/allowed non-physician practitioner (NPP) orders are required to begin home care services…” 7. During an interview with the Administrator and Nursing Supervisor on 12/4/24 at 11:30 AM and at 2:45 PM, it was stated that the RN should conduct the initial comprehensive assessment within 24-48 hours of the referral or the Physician SOC order date. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 10/30/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 12/3/24. The clinical record included the “OASIS-E Start of Care” assessment form completed by the SN on 10/30/24. As of 12/3/24, the record lacked a referral or Physician order to initiate service on 10/30/24. 2. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the “OASIS-E Start of Care” assessment form completed by the SN on 10/25/24. As of 12/3/24, the record lacked a referral or Physician order to initiate service on 10/25/24. 3. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record was reviewed on 12/4/24. The clinical record included the “OASIS-E Start of Care” assessment form completed by the SN on 3/24/22. As of 12/4/24, the record lacked a referral or Physician order to initiate service on 3/24/22.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined that in 5 of 7 (Pts. #1, 2, 7, 3 and 6) clinical records reviewed, the Agency failed to ensure staff provide treatment or service, as ordered by the Physician. 3. Pt. #3 was admitted to home health services with the diagnosis of Congenital Hypothyroidism without Goiter. The clinical record was reviewed on 12/4/24. The clinical record included the POC effective 10/23/24 which required, “SN Frequency: 1wk9.” The clinical record lacked documentation of a second SN visit for the week of 10/27/24 to 11/2/24. The clinical record also lacked a Physician order indicating a change in the SN visit frequency. 4. Pt. #6 was admitted to home health services with the diagnosis of Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 12/4/24. The clinical record included the POC for the certification period of 3/4/24 to 5/2/24 which required, “MSW Frequency: 1w1.” As of 12/5/24, the clinical record lacked documentation of a MSW visit. 5. The Agency policy titled, “Physician/Allowed Non-Physician Practitioner (NPP) Orders” was reviewed on 12/5/24 and required, “Policy: All medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP).” 5. During staff interview with the Administrator and Nursing Supervisor on 12/4/24 at 11:30 AM and at 2:45 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 10/30/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 12/3/24. The clinical record included the POC dated 10/30/24 that required, “SN Frequency: 1 wk9… SN to perform medication review each skilled nursing visit…” The SN visit notes dated 11/5/24, 11/9/24, and 11/18/24 lacked a medication review; and lacked a Physician order for the second SN visit conducted during the week of 11/3/24 to 11/9/24 (11/9/24). The POC dated 10/30/24 required, “SN for observation/assessment of pain…” The SN visit note dated 11/18/24 lacked a pain assessment. 2. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the POC dated 10/25/24 that required, “SN Frequency: 1 W 9… SN to perform medication review each skilled nursing visit and reconcile medications as indicated”. The POC and Medication Profile, both dated 10/25/24 contained “Carvedilol 3.125 MG Oral Tablet 1 Tablet Daily By mouth (PO), Fluticasone Propionate 220 MCG 2 Puffs Twice Daily, …Good Sense Pain Relief Extra St (Strength) 500 MG Oral Tablet 1 tablet every 6 hours as needed By mouth (PO), Tylenol Extra Strength 500 MG Oral Tablet 1 tablet every 6 hours as needed By mouth (PO), Hydrochlorothiazide 25 MG Oral Tablet 1 Tablet Daily By mouth (PO), Lisinopril-Hydrochlorothiazide 10 MG-12.5 MG Oral Tablet 1 tablet daily By mouth (PO)”. A home visit was conducted on 12/3/24 with Employee #5. During the home visit, the medications were observed, and an interview was conducted with Pt. #2. Observed Vitamin D 50 MCG (2000 UT) tablet Take 1 tablet by mouth daily (labeled with the original date “09/03/2024”. Observed “Carvedilol 6.25 MG 1 Tablet twice a day by mouth”, the Pt. stated there were no changes with this medication since the SOC on 10/25/24. Pt. #2 stated, Fluticasone Propionate was discontinued “about a month ago”. The Pt. stated, GoodSense Pain Relief was discontinued by the Physician “about a month ago”, duplicate drug therapy was identified, the Pt. is also taking Tylenol Extra Strength. Pt. #2 stated Hydrochlorothiazide was discontinued by the Physician “about a month ago”, duplicate drug therapy identified, the Pt. is also taking Lisinopril-Hydrochlorothiazide. Pt. #2 stated the SN was aware of the medication changes. The POC lacked Vitamin D. The weekly SN visit notes dated 11/14/24 and 11/26/24 lacked a medication review. The record lacked documentation the SN reviewed and reconciled the medications as required in the POC. The POC dated 10/25/24 required, “Notify Physician of… Pain Level: greater than (>) 7 /10 (Pain level rating: 0 equal no pain, to 10 that equal severe pain). The weekly SN visit note dated 11/26/24 lacked documentation the SN assessed Pt. #2 for pain. 3. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included the POC for the certification period of 11/19/22 to 1/17/23 that required the SN to “Cleanse wounds with Betadine, apply triple antibiotic to wound bed, apply Calcium Alginate to wound bed, cover with ABD pad and wrap with kerlix”. The “OASIS-E Recertification” assessment form completed by the SN and dated 1/17/23 contained, the SN cleaned Wounds #1 (left lateral ankle), #2 (left medial ankle), and #3 (left medial calf) with “normal saline”. The SN failed to provide wound care as ordered in the POC.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined in 1 of 7 (Pt. #7) clinical records reviewed, the Agency failed to ensure there was coordination of care between care providers to ensure Pt. needs were met. Findings include: 1. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included the weekly SN visit notes from 11/25/22 to 2/10/23 that included the Pt. had 3 open wounds (Wound #1- left lateral ankle; Wound #2- left medial ankle; Wound #3- left medial calf). The POC for the certification period of 11/19/22 to 1/17/23 included “Patient’s personal healthcare goal(s): wounds will heal…”. The same POC required the SN/caregiver “Cleanse wounds with Betadine, apply triple antibiotic to wound bed, apply Calcium Alginate to wound bed, cover with ABD pad and wrap with kerlix. Wound dressing to be done twice weekly and as needed…” The SN visit notes from 11/25/22 to 2/10/23 lacked any improvement in the wounds, utilizing the wound care described above. The record lacked documentation that the SN notified the Physician that Pt. outcomes were not being met, and that the Pt. required a different wound care treatment. The “Social Work Discharge” note completed by the MSW on 9/6/22 contained, “Pt. suffers from Dementia and need 24/7 care. Daughter is overwhelmed… MSW recommended increasing private care, SNF (Skilled Nursing Facility), and respite, daughter declined…” The record included an “OASIS-E Death at Home” assessment form completed by the SN, dated 2/13/23; and the Physician order dated 2/13/23 with communication that the Pt. died at home. The record lacked documentation the SN coordinated care with the Physician regarding the social issues in home. 2. The Agency’s policy titled; “Medical Supervision” was reviewed on 12/5/24. The policy required, “… Purpose To assure the participation of physicians/allowed non-physician practitioners (NPP) in the development and maintaining of the client plan of care… Special Instructions… 4. Physician/allowed non-physician practitioner (NPP) will be contacted when any of the following occurs… d. Caregiver support or home environment changes… 13. Agency Responsibilities include… d. Periodic updates on client condition/progress…” 3. During staff interviews with the Administrator, and Nursing Supervisor on 12/4/24 at 2:45 PM, both confirmed the SN failed to coordinate care between health providers to ensure Pt. outcomes were met and address social issues in the home.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined in 1 of 1 (Pt. #7) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included Home Health Aide visit notes, 2 times a week from 11/23/22 to 2/9/23 that contained documentation the Home Health Aide provided personal care. As of 12/3/24, the record lacked documentation the RN supervised the Home Health Aide from 11/23/22 to 2/9/23. 2. During staff interviews with the Administrator, and Nursing Supervisor on 12/4/24 at 2:45 PM, both confirmed the RN failed to conduct Home Health Aide supervision every 14 days.”

“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 visits, clinical record reviews, Agency policy and staff interview, it was determined in 4 of 7 (Pts. #2, 7, 3 and 4) clinical records reviewed, the Agency failed to ensure the clinical record was complete and accurate, and that clinical notes included documentation relative to the services provided. 3. Pt. #3 was admitted to home health services on 9/27/24 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease. The clinical record was reviewed on 12/3/24. The SN visit notes dated 9/30/24, 11/6/24, 11/14/24 and 11/27/24 lacked documentation of Pt. #3’s weight. During an interview conducted with the visiting RN/Nursing Supervisor on 12/5/24 at 12:00 PM, it was stated that Pt. #3’s weight should be recorded weekly. 4. Pt. #4 was admitted to home health services on 9/27/24 with the diagnosis of Congenital Hypothyroidism without Goiter. The clinical record was reviewed on 12/3/24. The SN visit notes dated 11/6/24, 11/13/24, 11/20/24 and 11/27/24 lacked documentation of interventions, response to care/treatment and goals. 5. The Agency document titled, “Clinical Documentation” was reviewed on 12/5/24 and required, “Purpose: To ensure that there is an accurate record of the services provided, client response and ongoing need for care.” 6. During staff interviews with the Administrator and Nursing Supervisor on 12/4/24 at 11:30 AM and at 2:45 PM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the weekly SN visit notes from 10/31/24 to 11/26/24 lacked documentation of any SN interventions and response to treatment/services provided during the visits. 2. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The clinical record was reviewed on 12/3/24. The clinical record included the POC for the certification period of 11/19/22 to 1/17/23 which included documentation that Pt. #7 had 8 wounds, identified as Wound #1 (left lateral ankle), Wound #2 (left medial ankle), Wound #3 (left medial calf, Wound #4 (right lateral foot), Wound #5 (right heel), Wound #7 (right buttock), Wound #8 (left posterior heel), and Wound #9 (left mid foot). The POC effective 11/19/22 required the SN to provide wound care weekly and instruct the caregiver on performing the wound care. The weekly SN visit notes from 11/25/22 to 1/6/23, and the “OASIS-E Recertification” assessment form completed by the SN and dated 1/17/23 lacked any documentation pertaining to Wounds #5, #7, #8, and #9, including a description of the wounds or whether wound care was provided. During an interview with the Administrator on 12/4/24 at 2:45 PM, the Administrator stated Pt. #7 did have 8 wounds as described in the POC dated 11/19/24. During the same interview, the Administrator confirmed the SN visit notes indicated above lacked any documentation pertaining to Wounds #5 #7, #8, and #9.”