Advisacare

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Emergency Preparedness plan had been updated and reviewed at least every 2 years. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all 22 patients actively serviced by this Agency in the event of an actual emergency or disaster. Findings include: On 4/30/24 at 1:30 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the plan itself was undated. There was no documented evidence that the plan had been reviewed or updated as per this requirement. On 4/30/24 at 3:40 p.m., the Executive Director (ED #1) was queried as to whether the Governing Board did a review of the Emergency Preparedness plan. ED #1 provided a Governing Board document, however, there was no evidence that the Emergency Preparedness plan had been updated or reviewed. These findings were reviewed with and acknowledged by ED #1 at the time of discovery.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 1 (P-3) patient observed during a home visit from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-3: The patient’s start of care was 1/25/24 with diagnoses that included Guillain-Barre Syndrome, Bladder Cancer and Aphasia with Tracheostomy. During the record review on 4/30/24 at 11:10 a.m., it was noted that the plan of care ordered Occupational Therapy (OT) and Physical Therapy (PT) services to be provided. On 5/1/24 at 10:30 a.m., during a scheduled survey home visit with the OT, the following was observed: OT #1 assisted the patient with toileting, dressing and performing therapeutic exercises. The patient participated in retrieving rubber suction devices from her table to aid in mobility and applying socks to her lower extremities with use of a Sock Aid. When the tasks were completed, OT #1 placed the Sock Aid on the floor. The suction cups were placed back inside a box. Upon completion of the visit, OT #1 placed the above-mentioned equipment in her work bag. OT #1 failed to clean her equipment prior to placing them in her work bag. These findings were reviewed with and acknowledged by the Administrator and Executive Director during an interview on 5/2/24 at 10:35 a.m. who offered no response.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide documented evidence that infection control education was provided to all staff employed by this agency, resulting in the potential for the development and spread of infection to staff and all 22 patients currently serviced by this agency. Findings include: On 4/30/24 at 1:30 p.m., a request was made to review documented evidence of staff training/in-services in Infection Control. The Administrator (Adm #1) provided several documents with titles of in-services conducted. There was no indication of what the in-services entailed. A document titled, “Orientation Checklist” for the Home Health Aide revealed the Aide’s hire date was 5/4/23. The document was dated the same and all areas on the form, including topics of OSHA Compliance, TB and Infection Control Standards, were left blank. There was no sufficient documented evidence that all staff employed by this agency received training and in-services in Infection Control as per this requirement. These findings were reviewed with and acknowledged by Adm #1 and the Executive Director (ED #1) during an interview on 4/30/24 at 2:18 p.m.”

“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 record review and interview, the agency failed to ensure the registered nurse prepared written patient care instructions that included safety measures for 1 of 2 (P-4) records reviewed in which aide services were provided, resulting in a lack of direction regarding the safety needs of this patient. Findings include: P-4: This 93-year-old patient was admitted to home care on 2/24/24 with diagnoses of a urinary tract infection, hypo-osmolality with hyponatremia (retention of water by loss of sodium). The 2/24/24 plan of care ordered the aide to provide services once weekly for four weeks. The plan of care included safety measures of anticoagulant precautions due to the patient’s daily medication of Eliquis (anticoagulant medication). The patient is at risk of bleeding while on this medication. During record review on 4/29/24, it was noted that the aide care was developed by the Administrator (Adm #1) on 2/25/24. The aide care plan failed to include the safety measure of anticoagulant precautions to alert the aide to the patient’s increased risk of bleeding. The findings were reviewed with and acknowledged by Adm #1 during an interview on 5/1/24 at 10:30 a.m.”

“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 record review and interview, the agency failed to ensure the registered nurse conducted the initial assessment visit to determine the immediate care needs of the patient, including homebound status for 2 of 4 (P-4 and P-1) records reviewed in which both skilled nursing and therapy services were ordered, resulting in the potential for unmet nursing care needs. Findings include: P-1: The patient’s Start of Care was 1/20/24 with diagnoses that included Acute Bronchitis, Respiratory Failure and Hypertension. During the clinical record review on 4/29/24 at 11:00 a.m., it was noted that the referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Home Health Aide (HHa) and Medical Social Work (MSW) services to be provided. At the time of the review, it was noted that the PT conducted the Initial Comprehensive Assessment and the SN saw the patient 3 days later. The agency failed to ensure the nurse conducted the initial assessment in order to determine the patient’s immediate care needs and homebound status. These findings were reviewed with and acknowledged by the Administrator and Executive Director during an interview on 5/2/24 at 10:00 a.m. P-4: This 93-year-old patient was recently hospitalized for a urinary tract infection and hypokalemia. The agency received the referral for home care services on 2/22/24 (fax stamped). The referral ordered nursing services, physical therapy, occupational therapy, and home health aide services. During record review on 4/29/24, it was noted that the physical therapist conducted the comprehensive assessment on 2/24/24. The registered nurse (RN) conducted an evaluation two days later (2/26/24). The RN and the physical therapist failed to follow the agency’s policy III.8 titled, Comprehensive Assessment and OASIS Data Collection Start of Care (not dated), which states; when RN and therapy services are ordered at the start of care, the RN would perform the start of care comprehensive assessment. The findings were reviewed with the Administrator (Adm #1) and the Executive Director (ED #1) during an interview on 5/1/24 at 10:30 a.m. Adm #1 stated that she was unaware that nursing had to conduct the initial assessment visit when nursing is on the case.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to ensure the patient’s activity of daily living needs were adequately met in the patient’s home for 1 (P-3) patient observed during a home visit, who required assistance with grooming and toileting, from a total of 7 sampled patients reviewed, resulting in low self-esteem and the potential for unmet care needs. Findings include: P-3: The patient’s start of care was 1/25/24. The period of review was 3/25/24 through 5/2/24 with diagnoses that included Guillain-Barre Syndrome, Bladder Cancer, Aphasia with Tracheostomy and Falls. On 4/30/24 at 11:10 a.m. during the clinical record review it was noted that section M1800 of the Initial Comprehensive Assessment documented, “someone must assist the patient to groom self, someone must help put on upper body clothing, depends entirely upon another person to dress lower body, unable to participate effectively in bathing and is bathed totally by another person, is totally dependent in toileting, depends entirely upon another person to maintain toileting hygiene...” On 5/1/24 at 10:30 a.m., during a scheduled survey home visit with the Occupational Therapist (OT #1) the patient was observed seated in a wheelchair. During the visit, the patient became tearful and expressed feelings of “frustration and embarrassment” as she expressed needing assistance with toileting and grooming and not receiving enough help. During the visit, OT #1 elaborated that the patient had expressed her concerns during a prior discussion. Further review of the clinical record revealed no documented evidence that Home Health Aide services had been offered to assist with toileting and grooming. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Executive Director (ED #1) during an interview on 5/2/24 at 10:35 a.m. to which ED #1 responded, “I think we should get an aide out there 3 times a week to start.””

“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 the comprehensive assessment included a review of all medications to determine any adverse effects; failed to provide documented evidence of the drug regime review: failed to ensure the Registered Nurse provided oversight of the review process, and failed to ensure the physician was notified of potential drug interactions in 2 (P-1, P-3) records, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-1: The patient’s start of care (SOC) was 1/20/24 with diagnoses that included Acute Bronchitis, Respiratory Failure and Hypertension. Section M2001 (Drug Regimen Review) of the Initial Comprehensive Assessment, completed by the Physical Therapist (PT), documented “No issues found during review.” There was no documentation available for review to support that a drug review had been conducted. The patient’s 15 prescribed medications were entered in Drugs.com (online drug interaction checker) and revealed 1 Major drug to drug interaction, 16 moderate drug to drug interactions and 1 Major drug to food interaction. During the record review on 4/29/24 at 11:00 a.m., there was no documented evidence that the Registered Nurse (RN) conducted the drug review as per this requirement. Additionally, during the Entrance Conference on 4/29/24, the Administrator stated that all Major and Moderate drug interactions are to be reported to the Physician. There was no evidence that any of the above findings had been reported as stated. The agency failed to ensure the comprehensive assessment included an accurate review of the patient’s medications conducted by an RN. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/2/24 at 10:00 a.m. who reported, “I don’t see that a drug review was actually conducted.” P-3: The patient’s SOC was 1/25/24 with diagnoses that included Guillain-Barre Syndrome, Bladder Cancer and Aphasia with Tracheostomy. Section M2001 of the Initial Comprehensive Assessment was completed by the Physical Therapist and documented “No issues found during review. There was no documented evidence that the RN conducted the review as per this requirement. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/2/24 at 10:35 a.m.”

“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 agency failed to ensure the plan of care included measurable outcomes and goals for 1 of 5 (P-7) records reviewed with skilled nursing care, resulting in the potential for poor patient outcomes for this patient. Findings include: P-7: This patient was admitted to home care services on 4/6/24 with diagnoses of hypertensive heart & kidney disease with heart failure and with stage 5 chronic kidney disease. The patient is scheduled for dialysis 3 days per week. The 4/6/24 plan of care includes the following skilled nursing interventions: instruct patient/caregiver to weigh daily and to report variations of 2 pounds in 24 hours or 5 pounds in 7 days to the doctor, instruct patient to log weights daily, clinicians to monitor. During record review on 4/30/24, it was noted that the plan of care failed to include measurable outcomes and goals for the skilled nurse to determine the patient’s progress towards discharge. There were no goals related to the patient’s or the clinician’s monitoring of daily weights. The plan of care included the following skilled nursing goals for this patient: patient will verbalize understanding of disease process, management and when to seek medical attention. It was unclear how this goal was to be measured to determine progress towards discharge. The plan of care also contained this goal: patient will have diagnosis specific interventions throughout this episode of care to monitor co-morbidities and potential adverse events to reduce the risk of acute hospitalization. Diagnosis specific interventions are established by the nurse. This is not a goal for the patient to achieve to determine progress towards discharge. The findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Executive Director (ED #1) during an interview on 5/1/24 at 10:30 a.m.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was advised of the ordered disciplines and their visit frequency prior to the provision of care and services for 1 (P-1) patient ordered to receive home health services, from a total of 7 sampled records reviewed, resulting in the patient not having a say in the planning of care. Findings include: P-1: The patient’s start of care (SOC) was 1/20/24 with diagnoses that included Acute Bronchitis, Respiratory Failure and Hypertension. The patient was discharged from home care services on 2/9/24. During the clinical record review on 4/29/24 at 11:00 a.m., it was noted that the referral for home care dated 1/18/24, ordered Physical Therapy (PT), Occupational Therapy (OT), Skilled Nursing (SN), Home Health Aide (HHa) and Medical social Work (MSW) services to be provided. The “Consent for Care/Service” dated 1/20/24 failed to included disciplines ordered and frequencies for SN, OT, HHA and MSW services. These findings were reviewed with and acknowledged by the Administrator and Executive Director during an interview on 5/2/24 at 10:00 a.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure Medical Social Work services were provided as ordered by the Physician and the Plan of Care for 1 (P-1) patient who required assistance with resources, from a total of 7 sampled records reviewed, resulting in a lack of assistance with acquiring needed resources. Findings include: P-1: The patient’s start of care was 1/20/24 with diagnoses that included Acute Bronchitis, Respiratory Failure and Hypertension. During the clinical record review on 4/29/24 at 11:00 a.m., it was noted that the referral for home care, dated 1/18/24, ordered MSW services to be provided for “community resources. The patient was discharged from the agency’s services on 2/9/24. At the time of this record review, MSW services had not been provided as ordered. These findings were reviewed with and acknowledged by the Administrator and Executive Director during an interview on 5/2/24 at 10:00 a.m.”

“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 record review and interview, the agency failed to ensure a discharge summary was completed, detailing the course of care provided, responses to treatment and the health status of the patient at the time of discharge, and failed to ensure the summaries were forwarded to the Physician within 5 days of the date of discharge for 1 (P-1) of 2 patients discharged from the agency’s services, from a total of 7 sampled records reviewed, resulting in the Physician not having a clear clinical picture of the status of the patient at the time of discharge and the potential for unidentified continuing care needs. Findings include: P-1: The patient’s start of care was 1/20/24 with diagnoses that included Acute Bronchitis, Respiratory Failure and Hypertension. During the clinical record review on 4/29/24 at 11:00 a.m., it was noted that the referral for home care ordered Physical Therapy, Occupational Therapy, Skilled Nursing, Medical Social Work and Home Health Aide services to be provided. The patient’s last Occupational Therapy visit was conducted on 2/2/24. At the time of this review, no Occupational Therapy discharge summary had been completed. The patient discharged from Physical Therapy and the agency’s services on 2/9/24. The summary of care was inconsistent and documented the patient’s pain level at the time of discharge as 4/10, however, it was stated that the patient expressed relief at pain level 6/10. Additionally, there was no documented evidence that the Physical Therapy discharge summary had been forwarded to the Physician within 5 days of the patient’s discharge from the agency’s services. These findings were reviewed with and acknowledged by the Administrator and Executive Director during an interview on 5/2/24 at 10:00 a.m.”