Elite Home Rehab and Healthcare Corp

“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 record review and interview, the home health agency failed to communicate with the patient regarding missed visits for 1 of 5 discharged records reviewed. (Patient #15) Findings Include: 1. A review of agency policy “Patient Bill of Rights”, indicated that the patient has the right to receive and access services consistently, with continuity, and in a timely manner from the agency to his/her request for service. The agency must document its communication with the patient, as well as the measures the Agency took to get in contact with the patient. 2. A review of a list of agency patients discharged indicated Patient #15 was discharged on 11/14/2023, reason documented was “patient refused care.” 3. A review of documents titled “Missed Visit Note”, dated 11/07/2023 and 11/08/2023 indicated that Patient #15 did not answer phone calls from the agency and that the physician was made aware of the missed visits. 4. A review of Patient #15’s schedule in the electronic medical record indicated a lack of documentation by the agency of visit notes, missed visit notes, or attempted contacts to reach the patient starting the week of 10/15/2023 through the week of 11/04/2023. No documentation of attempts to reach Patient #15 was provided until 11/07/2023, a missed visit note with an attempted phone call. 5. A review of document titled “Home Health Certification and Plan of Care”, dated 10/25/2023, certification period 10/17/2023 to 12/15/2023 indicated Patient #15 was to have a skilled nurse visit once a week for nine weeks. 6. During an interview on 12/11/2023 at 3:31 PM, the Administrator indicated that all documentation regarding phone calls and missed visits for Patient #15 had been provided to the surveyor and that no other documentation regarding attempted contacts/missed visit notes were documented. 7. During an interview on 12/11/2023 the Administrator indicated that staff are to contact patients and leave a voicemail for the patient to call back if unavailable. Staff are to call a couple times and if the patient still does not answer or call back, we get the Marketer involved and have them go to the patients house and contact them that way. 8. During an interview on 12/11/2023 at 9:26 AM, PT #2 indicated that missed visits are to be rescheduled for the same week, the physician is to be notified, with attempts to get in contact with patients any way they can.”

“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 observation, record review, and interview, the home health agency failed to ensure all required elements were included in the plan of care (POC) for 2 of 2 patients both receiving anticoagulant (blood thinner) therapy and with home visit observations (Patient #1 and #3). Findings include: 1. The Patient Assessments / Plan of Care policy indicated the plan of care (POC) must include the patient’s required equipment, all medications, and safety measures to protect against injury. 2. The Medication Review policy indicated the medication profile should include all current patient medications, including but not limited to the dosage and frequency, and that drug regimen review should occur as an ongoing part of the patient’s care. 3. During a home visit observation on 12/04/23, Registered Nurse (RN) 1 provided care for Patient #1. A hospital bed and bedside commode were in the patient’s home. Tylenol, a medication used to relieve minor pain and fever, 500 milligrams (mg) and an Albuterol inhaler, a medication that helps open the airway to make breathing easier, with instructions to take 2 puffs as needed for wheezing or shortness of breath was also located in the home. Patient #1 indicated they used the Tylenol as needed for pain since before beginning agency services and had been using the inhaler as needed for 1 week for wheezing. During an interview on 12/05/23 at 4:02 PM, the Clinical Manager relayed all equipment and supplies used by the patient should be in the POC and indicated the POC did not include a hospital bed or bedside commode. The Clinical Manager indicated all medications the patient is taking should be included in the POC medication list but that Tylenol and Albuterol inhaler were not included in Patient #1’s POC medication list. During an interview on 12/06/23 at 4:28 PM, the Administrator indicated bleeding precautions should be included in the POC for a patient on anticoagulant therapy and that Patient #1’s POC did not include bleeding precautions. Patient #1’s clinical record included a POC for certification period 11/17/23 to 01/15/24 which failed to evidence a hospital bed or bedside commode. The POC failed to evidence Tylenol or an albuterol inhaler on the medication list. The POC included Eliquis, a medication used to reduce blood clotting, 2.5 mg oral tablet to be taken twice daily. The POC failed to evidence bleeding precautions for Patient #1. 4. During a home visit observation on 12/05/23, Physical Therapy Assistant (PTA) 1 provided care for Patient #3. Received a facility medication list from Entity 1’s licensed practical nurse. Entity 1’s medication list indicated Patient #3’s required medications to be administered by the facility and included but not limited to Acetaminophen, a medication used to treat pain and fever, 325 mg with instructions to take 1 tablet by mouth 3 times per day as needed; Vitamin B-12 1,000 micrograms tablet daily; Ferrous Sulfate (Iron) 325 mg tablet with instructions to discontinue on 12/1/23; Sodium Bicarbonate, a medication used to relieve heartburn and indigestion or to make the blood or urine less acidic, 325 mg tablet twice daily; Neosporin, an antibiotic ointment, applied to left great toe; Calmoseptine ointment, a barrier cream used to protect and help heal skin irritations, topically to bilateral glutes (buttocks), coccyx (tailbone), and groin every 4 hours as needed following incontinence care; and Fungi-nail, a medication used to treat nail fungus, with instructions to apply to right toenail twice daily as needed. Patient #3’s clinical record included a POC for certification period 10/20/23 to 12/18/23 which included Acetaminophen 325 mg oral tablet every 4 hours as needed for pain; Diclofenac Sodium, a medication used to treat swelling and pain, 50 mg oral delayed release tablet twice daily as needed for pain, Diclofenac Sodium 75 mg oral tablet twice daily, Ferrous Sulfate 325 mg oral tablet twice daily, and Vitamin B complex tablet. The POC failed to include the correct dosage and frequency for Acetaminophen and failed to include Vitamin B-12, Sodium Bicarbonate, Neosporin, Calmoseptine ointment, and Fungi-nail. The POC incorrectly included Diclofenac Sodium, Ferrous Sulfate, and Vitamin B complex. The POC included the anticoagulant Xarelto, a medication used to treat and prevent blood clots. The POC failed to include bleeding precautions for Patient #3. During an interview on 12/08/23 at 3:14 PM, the Administrator indicated the agency’s medication list should include the same information as the ALF’s medication list and relayed the agency’s POC medication list did not include the same dosage and frequency as Entity 1’s medication list for Acetaminophen and did not include the Vitamin B-12, Sodium Bicarbonate, Neosporin, Calmoseptine ointment, and Fungi-nail that were included in Entity 1’s medication list. The Administrator relayed the POC included Ferrous Sulfate and Vitamin B complex and that the Diclofenac from the agency POC was not included in Entity 1’s medication list. During an interview on 12/06/23 at 4:28 PM, the Administrator indicated bleeding precautions should be included in the POC for a patient on anticoagulant therapy. During an interview on 12/08/23 at 3:14 PM, the Administrator relayed Patient #3’s POC did not include bleeding precautions.”

“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 record review and interview the home health agency failed to ensure physician orders were obtained prior to clinicians providing care for 2 of 2 patients both receiving anticoagulant (blood thinner) therapy and with home visit observations (Patient #1 and #3.) Findings include: 1. The Verbal Orders policy indicated physician orders, which are signed, timed, and dated by the physician, are required for all services rendered by the agency and verbal orders are to be recorded in the patient’s clinical record by the professional receiving them and must include the date, time, and signature. 2. Patient #1’s clinical record included a plan of care (POC) for certification period 11/17/23 to 01/15/24 which the agency received signed by the physician on 12/07/23. Patient #1’s clinical record included skilled nursing (SN) visits where wound care was performed on 11/20/23, 11/22/23, 11/24/23, 11/27/23, 11/29/23, 12/01/23, and 12/04/23. The clinical record failed to evidence the agency had physician orders for these visits. During an interview on 12/07/23 at 2:26 PM, RN 1 relayed they had left a message for Patient #1’s physician with the POC details but had not received a call back with verbal orders for the services and frequencies included in the POC. During an interview on 12/08/23 at 3:14 PM, the Administrator relayed their expectation for a verbal order included the clinician speaking with someone in the patient’s provider’s office and receiving verbal confirmation of the requested order. 3. Patient #3’s clinical record included a POC for certification period 10/20/23 to 12/18/23 which the agency received signed by the physician on 10/24/23. Patient #3’s clinical record included a SN visit with wound care performed on 10/23/23 and a physical therapy assistant (PTA) visit with therapy services provided on 10/20/23. The clinical record failed to evidence the agency had physician orders for these visits. During an interview on 12/08/23 at 9:07 AM, RN 2 relayed they did not receive a verbal order for services and frequencies included in the POC and that the POC had been faxed to the physician’s office on 10/20/23 for review and signature and had been received back signed by the physician on 10/24/23. During an interview on 12/08/23 at 3:14 PM, the Administrator relayed their expectation for a verbal order included the clinician speaking with someone in the patient’s provider’s office and receiving verbal confirmation of the requested order.”