Christian Home Health Care, Inc.

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview the agency failed to meet the Condition of Participation of Care Planning, Coordination of Services, and Quality of Care as evidenced by: 1.Failure of the HHA to provide patient care based upon a current, working, individualized plan of care based on physician’s orders for 2 (Patient #1 and Patient #2) of 2 (Patient #1 and Patient #2) active sampled patients. This deficient practice was evidenced by failure to have a complete medical record for each patient that contained physician’s orders, progress notes, medication orders, and nurses notes since the provider lost access to electronic medical records in April 2024 for 2 (Patient #1 and Patient #2) of 2 active sampled patients from a total census of 2 active patients. This deficient practice was discovered on a home visit for Patient #2 on 08/28/2024 at 10:20 a.m. when S2DON indicated she reconciled Patient #2’s medications by viewing the labels on the plastic medication bottles without the presence of a copy of medication orders. This deficient practice resulted in an Immediate Jeopardy situation being declared on 08/29/2024 at 12:00 p.m. after a home visit confirmed that Patient #1’s home folder did not contain any physician’s orders, medication orders, progress notes, or nurses notes to maintain an individualized plan of care for Patient #1; and the agency could not produce any notes or current orders upon return to the agency office. S1Administrator was notified of the Immediate Jeopardy on 8/29/2024 at 4:41 p.m. Onsite verification that the agency had implemented an acceptable Plan of Removal (POR) was made through observations, record reviews, and interviews. Record review revealed documentation on paper nurse assessment and medication reconciliation forms from recent skilled nursing visits for Patient #1 and Patient #2, and copies of the documents were available in the patients’ home chart binders and office chart binders. Further review revealed documentation of completed staff training. The Immediacy of the Immediate Jeopardy situation was lifted on 09/03/0224 at 3:21 p.m. prior to the survey exit. (see findings in G-574). 2. Failure of the HHA to ensure HHA staff were providing services from a working current plan of care, that was updated to reflect all current ongoing patient care orders, including medication orders, wound care orders, and skilled nursing orders, for 2 (Patient #1 and Patient #2) of 2 active sampled patients from a total census of 2 active patients (Patient #1 and Patient #2). (see findings in G-576). (see findings in G-574). (see findings in G-576).”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop emergency preparedness policies and procedures which addressed the use of volunteers in an emergency. Findings: Review of the agency’s Emergency Preparedness Plan policy and procedure revealed, in part, no documented evidence, and the agency presented no documented evidence that the agency had policies and procedures which addressed the use of volunteers in an emergency or emergency staffing strategies. In an interview on 08/27/2024 at 3:50 p.m., S1Administrator indicated the agency did not have a policy or procedure which included the use of the volunteers and/or emergency staffing strategies in the event of an emergency.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record reviews and interview, the agency failed to maintain an agency-wide program for infection control, identification, and surveillance. This deficient practice could have affected any of the 28 unduplicated admissions in the last year. Findings: Review of the agency’s Infection Control binder revealed it consisted of an instruction page, blank forms, and no patient documentation. Record review revealed Patient #1 was admitted on 04/12/2024 with a diagnosis, in part, of Chronic Refractory Osteomyelitis. Record review revealed Patient #3 had a hospitalization while a patient of the agency in July of 2023 and had diagnoses, which included sepsis and possible diverticulitis and was administration of Intravenous (IV) antibiotics. Further review a diagnosis of osteomyelitis with spinal hardware removal in September of 2022. Record review revealed Patient #4 was admitted on 05/04/2023 with a diagnosis, in part, of Osteomyelitis of vertebra, sacral and sacrococcygeal region. There was no documented evidence and the provider did not present any documented evidence of maintaining an agency-wide program for infection control, identification, and surveillance. In an interview on 09/3/2024 at 2:05 p.m., S1Administrator indicated she did not know of any patients with infections or antibiotic use. When S1Administrator was made aware of patients with infections and antibiotic use, S1Administrator confirmed that some patients should have had documentation in the Infection Control binder.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure agency nursing staff reviewed correlation of identified patient home medications and current physician ordered medications for 2 (Patient #1 and Patient #2) of 2 active sampled patients from a total census of 2 active patients. This deficient practice was evidenced by failure of observed nursing staff (S2DON) to reconcile patients ( #1, #2) medications with patients’ medication orders for 2 ( #1, #2) of 2 patients observed during home visits. Findings: Observation on 08/28/2024 at 10:20 a.m. revealed S2Director of Nursing (DON) indicated to Patient #2 the home visit was over. At this time the surveyor asked Patient #2 about her medications. Patient #2 then indicated her medications were in the plastic medication prescription bottles in a zippered bag on the kitchen table. S2DON then began to pull each bottle of medication from the bag and showed each one to the surveyor. S2DON did not document anything from her observations of Patient #2’s medications. Further observation revealed Patient #2’s home folder did not contain any physician orders. S2DON did not have current medication orders to use to reconcile the patient’s medications. In an interview on 08/28/2024 at 10:40 a.m., S2DON indicated she knew Patient #2’s medications, and that she checked them on every home visit. Observation on 08/29/2024 at 11:07 a.m., revealed S2DON viewed Patient #1’s medication bottles, and did not document her observations of Patient #1’s medications. In an interview on 08/29/2024 at 11:17 a.m., S2DON indicated she knew all of Patient #1’s ordered medications, and Patient #1’s orders have not changed since April 2024 when he started getting care from the agency. S2DON confirmed that Patient #1 did not have a copy of his physician’s orders with his medications. S2DON answered that she reconciled Patient #1’s medications just by looking at the medication bottles because she knew his medication orders. S2DON showed a notebook with handwritten documentation of home visits, with dates and patient signatures, her signature, wound visit, and no other documentation. S2DON further indicated she did not have current medication orders for Patient #2 and could not answer that Patient #2 medication reconciliation on 08/28/2024 was accurate. In an interview on 08/29/2024 at 11:55 a.m., S1Administrator indicated the agency did not have current physician orders for Patient #1 or Patient #2 which were required for accurate medication reconciliation on each skilled nurse visit.”

“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 record review and interview the HHA failed provide patient care based upon a current, working, individualized plan of care based on physician’s orders for 2 (Patient #1 and Patient #2) of 2 (Patient #1 and Patient #2) active sampled patients. This deficient practice was evidenced by failure to have a complete medical record for each patient that contained physician’s orders, progress notes, medication orders, and nurses notes since the provider lost access to electronic medical records in April 2024 for 2 (Patient #1 and Patient #2) of 2 active sampled patients from a total census of 2 active patients. This deficient practice was discovered on a home visit for Patient #2 on 08/28/2024 at 10:20 a.m. when S2DON indicated she reconciled Patient #2’s medications by viewing the labels on the plastic medication bottles without the presence of a copy of medication orders. This deficient practice resulted in an Immediate Jeopardy situation being declared on 08/29/2024 at 12:00 p.m. after a home visit confirmed that Patient #1’s home folder did not contain any physician’s orders, medication orders, progress notes, or nurses notes to maintain an individualized plan of care for Patient #1; and the agency could not produce any notes or current orders upon return to the agency office. S1Administrator was notified of the Immediate Jeopardy on 8/29/2024 at 4:41 p.m. Onsite verification that the agency had implemented an acceptable Plan of Removal (POR) was made through observations, record reviews, and interviews. Record review revealed documentation on paper nurse assessment and medication reconciliation forms from recent skilled nursing visits for Patient #1 and Patient #2, and copies of the documents were available in the patients’ home chart binders and office chart binders. Further review revealed documentation of completed staff training. The Immediacy of the Immediate Jeopardy situation was lifted on 09/03/0224 at 3:21 p.m. prior to the survey exit. The deficient practice had the potential to cause harm to the current agency patients and any future admits. Findings: Record review on 08/27/2024 of electronic medical records (EMR) for Patient #1 and Patient #2 revealed no documentation since 04/02/2024. In an interview on 08/27/2024 at 1:30 p.m., S1Administrator indicated the agency had used a program, Alora, and was unable to maintain payment, and could not retrieve previously documented records. S1Administrator further indicated the agency reverted back to using Kinnser (a previously contracted EMR), and were unable to maintain payment since April 2024. S1Administrator indicated the agency would retrieve notes and signed visit logs from Patient #1 and Patient #2’s homes. S1Administrator acknowledged not all paper documentation for Patient #1 and Patient #2 was available at the agency’s office for review by the surveyor. Observations of Patient #2’s home visit on 08/28/2024 between 9:57 a.m. and 10:20 a.m. revealed no written individualized plan of care for Patient #2. Further observations revealed S2Director of Nursing (DON) did not document any observations she made of Patient #2’s medications, and did not have a copy of any physician orders for Patient #2. In an interview on 08/28/2024 at 10:40 a.m., S2DON indicated she knew Patient #2’s medications, and that she checked them on every home visit. Observation on 08/29/2024 at 11:07 a.m., revealed S2DON viewed Patient #1’s medication bottles, and did not document her observations of Patient #1’s medications. Further observation revealed Patient#1’s home folder revealed no written individualized plan of care for Patient #1. In an interview on 08/29/2024 at 11:17 a.m., S2DON indicated she knew all of Patient #1’s ordered medications, and Patient #1’s orders have not changed since April 2024 when he started getting care from our agency. S2DON confirmed that Patient #1 did not have a copy of his physician’s orders with his medications. S2DON again indicated she knew Patient #1’s current medications, and had a copy of his physician’s orders. S2DON showed a notebook with handwritten documentation of home visits, with dates and patient signatures, and no other documentation. S2DON further indicated she did not have current medication orders for Patient #2 and could not answer that Patient #2 medication reconciliation on 08/28/2024 was accurate. In an interview on 08/29/2024 at 11:55 a.m., S1Administrator indicated the patients’ home folders did not contain any orders or nursing notes, and the EMR had no documentation of patient care or patient orders. S1Administrator indicated the agency did not have electronic or paper records of documentation needed to maintain an accurate written individualized plan of care for Patient #1 or Patient #2.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview the HHA failed to ensure HHA staff were providing services from a working current plan of care, that was updated to reflect all current ongoing patient care orders, including medication orders, wound care orders, and skilled nursing orders, for 2 (Patient #1 and Patient #2) of 2 active sampled patients from a total census of 2 active patients (Patient #1 and Patient #2). Findings: Record review of electronic medical records (EMR) for Patient #1 and Patient #2 revealed no documentation since 04/02/2024. Observations of Patient #2’s home visit on 08/28/2024 between 9:57 a.m. and 10:20 a.m. revealed no patient care orders or a written individualized plan of care for Patient #2. Further observations revealed S2Director of Nursing (DON) did not have a copy any physician orders for Patient #2, when she reconciled Patient #2’s medications. Observation on 08/29/2024 at 11:07 a.m., revealed S2DON did not have a copy any physician orders for Patient #1, when she reconciled Patient #1’s medications. Further observation revealed Patient#1’s home folder revealed no patient care orders or a written individualized plan of care for Patient #1. In an interview on 08/29/2024 at 11:55 a.m., S1Administrator indicated the agency did not have current patient care orders for Patient #1 or Patient #2 which were required for maintaining individualized plans of care.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to implement an effective QAPI (Quality Assurance and Performance Improvement) program. Findings: Record review revealed the agency did not have a working EMR (electronic medical record) system since 04/05/2024. There was no documented evidence and the agency did not present any documented evidence of having electronic or paper medical charts in use and/or having a QAPI related to the above. In an interview on 08/27/2024 at 4:55 p.m., S1Administrator indicated S2Director of Nursing (DON) had identified topics for the QAPI program, including the agency’s issues with electronic medical records (EMR) issues in 2023 and 2024. In an interview on 08/29/2024 at 3:30 p.m., S1Administrator indicated the agency and the Governing Board were aware of documentation and billing issues with their EMR system for almost one year. When questioned about actions taken to correct the EMR issue, S1Administrator indicated the EMR system was not in use for lack of payment, and the agency did not switch to a paper charting system. S1Administrator acknowledged the QAPI program was ineffective.”