A-Plus Home Health Care, Inc.

“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 record review and interview, the agency failed to provide documented evidence of annual infection control education for 4 of 10 sampled staff members including those employed through an arranged contract, which has the potential to negatively impact the safety and well-being of all 89 patients serviced by the agency in the past 12 months. Findings include: On 10/31/24 at 10:00 am, an interview was conducted with the Administrator (Staff-A) regarding infection control education of staff. During the interview, query was made regarding when staff members received infection control education. Staff-A stated all staff receive infection control training at orientation and annually. Staff-A provided an in-service attendance sheet dated 9/11/24 with the topic “Infection control and standard precautions.” 6 of 10 staff members were in attendance and completed the training. Staff-A stated, “It’s tough to get everyone in here for the meetings. I will contact those remaining staff members and have them come into the office.” This finding was reviewed on 10/31/24 at the time of the finding with Staff-A.”

“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 agency failed to ensure the patient was able to be informed about, and consent or refuse care in advance of treatment with respect to the care being furnished based on the comprehensive assessment in 3 (P-1, P-3 and P-5) of 7 sample records reviewed resulting in the patient not receiving services which my have been beneficial during their recovery process. Findings include: P-5: This 70-year-old was admitted to the agency on 9/24/24 with diagnoses including cerebrovascular disease (disease affecting blood vessels in the brain); Osteoarthritis of both knees; and muscle weakness. The medical record was reviewed on 11/4/24. During review, it was noted that the physician orders on the referral dated 9/10/24 requested the following home health services: Nursing; Physical Therapy (PT); Occupational Therapy; and Home Health Aide. The PT completed the comprehensive assessment on 9/24/24 and documented that someone must assist the patient with grooming; upper and lower body dressing; bathing; toileting; and maintaining hygiene. The PT also documented that the patient lives alone and family was assisting “as and when needed”. There was no documentation that home health aide services were offered as requested on the orders for home care services. There was no documentation that the patient refused home health aide services. The patient was not given the opportunity to consent to or refuse the assistance of home health aide services. These findings were reviewed and acknowledged on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.m. Staff A stated that the order for home health aide services on the referral must have been missed during the intake process. **Agency Policy: “Bill of Rights - Patient” (Revised 1/2007). The policy states, “1. Notice of Rights. On the Initial Visit and before accepting the services of the agency, the Registered Nurse, Physical Therapist, or Speech Language Pathologist will provide the patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment…The Case manager will inform the patient the following rights: b) Right to be informed and participate in planning care and treatment…Must advise the patient in advance of the disciplines that will furnish the care, and the frequency of visits proposed to be furnished.” P-1: The Start of Care (SOC) was dated 10/10/24. The Plan of Care (POC) identified diagnoses of Hypertension and Low Back Pain. During record review on 10/30/24, it was noted that the referral stated “PT (Physical Therapy) / OT (Occupational Therapy) ordered.” The consent signed by the patient on 10/10/24 and the comprehensive assessment completed by the PT on 10/10/24 were blank under the OT section and there was no documentation of the patient refusing OT. The agency failed to provide services as ordered and consented to. P-3: The Start of Care (SOC) was dated 5/1/24. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Diabetes Type 2 and Hypertension. During record review on 10/31/24, it was noted that the referral stated, “Services Requested: SN (Skilled Nursing) … PT/OT … HHCA (Home Health Aide/HHA) …” The consent signed by the patient on 5/1/24 and the comprehensive assessment completed by the RN on 5/1/24 were blank under the OT and HHA section and there was no documentation of the patient refusing OT and HHA. The agency failed to provide services as ordered and consented to. These findings were reviewed with and acknowledged by the Staff-A (Administrator) during an interview on 11/6/24 at 10:50 am.”

“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 (RN) conducted the initial assessment when RN services were ordered in 3 (P-2, P-5 and P-6) of 7 sample records reviewed, and failed to ensure that an initial assessment was completed within 48 hours of referral or physicians ordered start of care date in 2 (P-4 and P-5) of 7 sample records reviewed resulting in a delay in assessment of immediate care and support needs, and the potential for poor patient outcomes. Findings include: P-2: The Start of Care (SOC) was dated 10/2/24. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 10/31/24, it was noted that the referral stated, “I certify that based on my findings, the following services are medically necessary for home health service and support the services: Nursing, Physical Therapy and Medical Social Worker.” On 10/2/24, the Physical Therapist completed a SOC OASIS (Outcome and Assessment Information Set). The Registered Nurse failed to complete the initial assessment visit. This finding was reviewed with and acknowledged by the Staff-A (Administrator) during an interview on 11/6/24 at 11:15 am. P-4: This 62-year-old was admitted to the agency on 6/17/24 with diagnoses including paralysis of left side following stroke; Osteoarthritis; and high blood pressure. The medical record was reviewed on 11/6/24. During review it was noted that the physician referral was dated 5/21/24 but was not faxed to the agency until 6/11/24. The PT completed the comprehensive assessment (initial visit) on 6/17/24, which was 6 days after the agency received notice of referral. There was no evidence in the medical record that a delay was requested by the patient. There was no updated physician order with another start of care request. The agency failed to complete an initial assessment within 48 hours of referral. P-5: This 70-year-old was admitted to the agency on 9/24/24 with diagnoses including cerebrovascular disease (disease affecting blood vessels in the brain); Osteoarthritis of both knees; and muscle weakness. The medical record was reviewed on 11/4/24. During review, it was noted that the physician orders on the referral signed 9/17/24, requested the following home health services: Nursing; Physical Therapy (PT); Occupational Therapy; and Home Health Aide. The PT completed the comprehensive assessment on 9/24/24. The Registered Nurse (RN) failed to provide an initial assessment as ordered. It was also noted that there was a form in P-5’s medical record titled “Start of Care (SOC) Initial Visit Delayed Conference Note” which was signed by the PT on 9/24/24 and included documentation that the patient/family requested a delay in start of care; the physician was notified of delay; and the agency was notified of the delay on 9/24/24 (7 days after the request for home care referral was received). It was unclear how the patient could have requested a delay in start of care on the same day services began with the agency. There were no physician orders with an updated start of care date. The agency failed to provide an initial assessment within 48 hours of referral. P-6: This 84-year-old was admitted to the agency on 9/23/24 with diagnoses including Spondylopathy of spine (disease affecting the spine); Osteoarthritis of the left shoulder; and muscle weakness. The medical record was reviewed on 11/4/24. During review, it was noted that the physician orders on the referral dated 9/6/24 requested the following home health services: Nursing; Physical Therapy (PT); Occupational Therapy; and Home Health Aide. The PT completed the comprehensive assessment on 9/23/24. The RN failed to provide an initial assessment as ordered. These findings were reviewed and acknowledged on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.m.”

“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 the patient was currently taking for significant drug interactions and duplicate drug therapy in 5 (P-1, P-2, P-5, P-6, and P-7) of 7 sample records reviewed potentially resulting in unknown complications related to medications and poor patient outcomes. Findings include: P-1: The Start of Care (SOC) was dated 10/10/24. The Plan of Care (POC) identified diagnoses of Hypertension and Low Back Pain. During record review on 10/30/24, a medication interaction report was completed in the Electronic Medical Record (EMR) and noted 1 duplicate therapy medications: Amlodipine Besylate and Lisinopril. There was no documented evidence, during the 10/30/24 clinical record review, that a drug interaction review had in fact been conducted or documented evidence that the physician had been notified of the above findings. P-2: The Start of Care (SOC) was dated 10/2/24. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 10/31/24, a medication interaction report was completed in the EMR and noted 1 duplicate therapy medications: Furosemide and Hydrochlorothiazide. There was no documented evidence, during the 10/31/24 clinical record review, that a drug interaction review had in fact been conducted or documented evidence that the physician had been notified of the above findings. These findings were reviewed with and acknowledged by the Staff-A (Administrator) during an interview on 11/6/24 at 10:45 am. Agency policy titled “Medication Management”, revised 03/2005, was reviewed on 11/6/24. On page 1-2., it stated “General Medication Administration… Staff review and record all medications the patient is taking upon initial assessment… Procedure… 1. Agency staff shall check all medications the patient is taking to identify and promptly report to the physician any significant side effects or contraindications, including the following… B. Medication incompatibility for potential interaction… F… Duplication of medications.” P-5: This 70-year-old was admitted to the agency on 9/24/24 with diagnoses including cerebrovascular disease (disease affecting blood vessels in the brain); Osteoarthritis of both knees; and muscle weakness. The medical record was reviewed on 11/4/24. The comprehensive assessment was completed by the physical therapist (PT) on 9/24/24 and documented that no issues were found during medication review and left the “Medication Follow-up” question regarding whether the physician was notified of any findings blank. This patient’s “Medications Interactions” report was provided on 11/4/24 by the agency Administrator (Staff A) and included 6 medications which had duplicate therapies; 7 medications with potential drug-drug interactions; and 3 drug-drug review suggested. There was no evidence in the medical record indicating that the physician had been notified or gave recommendation regarding any of the duplications/possible interactions identified. P-6: This 84-year-old was admitted to the agency on 9/23/24 with diagnoses including Spondylopathy of spine (disease affecting the spine); Osteoarthritis of the left shoulder; and muscle weakness. The medical record was reviewed on 11/4/24. The comprehensive assessment was completed by the PT on 9/23/24 and documented that no issues were found during medication review and left the “Medication Follow-up” question regarding whether the physician was notified of any findings blank. This patient’s “Medications Interactions” report was provided on 11/4/24 by Staff A and included 2 medications with duplicate therapy; 1 medication with potential drug-drug interaction; and 1 drug-drug review suggested. There was no evidence in the medical record indicating that the physician had been notified or gave recommendation regarding any of the duplications/possible interactions identified. P-7: This 66-year-old was admitted to the agency on 10/22/24 with diagnoses including Osteoarthritis both knees; muscle weakness; and high blood pressure. The medical record was reviewed on 10/31/24. The comprehensive assessment was completed by the PT on 10/22/24 and documented that no issues were found during medication review and left the “Medication Follow-up” question regarding whether the physician was notified of any findings blank. This patient’s “Medications Interactions” report was provided on 11/4/24 by Staff A and included 4 medications with duplicate therapy; 4 medications with potential drug-drug interactions; and 1 drug-drug review suggested. There was no evidence in the medical record indicating that the physician had been notified or gave recommendation regarding any of the duplications/possible interactions identified. These findings were reviewed and acknowledged on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.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 was individualized and included patient-specific measurable interventions, outcomes, and goals of care in 3 (P-3, P-4 and P-7) of 7 sample records reviewed resulting in the potential for unidentified and unmet patient goals of care, and lack of ability to determine progress towards them. Findings include: P-3: The Start of Care (SOC) was dated 5/1/24. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Diabetes Type 2 and Hypertension. During record review on 10/31/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “The pt’s (patients) safety will be enhanced throughout the home service as evidenced by no falls/injury within period of time.” Additionally, another goal stated, “The pt/cg (caregiver) will verbalize understanding of medications as evidenced by recall of action/dose/side effects within cert period of time.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. This finding was reviewed with and acknowledged by the Staff-A (Administrator) during an interview on 11/6/24 at 10:45 am. P-4: This 62-year-old was admitted to the agency on 6/17/24 with diagnoses including paralysis of left side following stroke; Osteoarthritis; and high blood pressure. The medical record was reviewed on 11/6/24. During review of the plan of care (POC) outcomes and goals for the certification period of 6/17/24 through 8/15/24, the following examples were noted: Return to pre-injury/illness level of function within 5 weeks; Return to optimal and safe functionality within 5 weeks; Patient will meet maximum rehab potential within 5 weeks; Demonstrate effective pain management within 5 weeks. It is unclear how these outcomes and goals were individualized to this patient or how they could be measured to determine progress (or lack of) toward them. P-7: This 66-year-old was admitted to the agency on 10/22/24 with diagnoses including Osteoarthritis both knees; muscle weakness; high blood pressure and type 2 Diabetes. The medical record was reviewed on 10/31/24. It was noted that the physical therapist (PT) completed the comprehensive start of care assessment on 10/22/24 and included documentation that the patient was diabetic, was insulin dependent, and used a glucometer to measure blood sugar. During continued review, it was noted that a POC was entered on 11/1/24 for the certification period of 10/22/24 through 12/20/24 (unsigned by any clinician). The POC contained orders for vital sign parameters and when to notify the physician including fasting blood sugar (FBS) results which were greater than 130 or less than 70, and random blood sugars (RBS) which were greater than 200 or less than 70. There were no interventions (including monitoring), outcomes, or goals listed for this patient’s active comorbid condition of type 2 Diabetes. These findings were reviewed and acknowledged on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.m.”

“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 observation, record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-3) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: **Agency Policy: “Physician Certification & Plan of Care (485),” (Revised 1/2007). The policy states, “1. The Plan of Care/485 is to be signed by a physician and shall be developed for each patient receiving the following home health and personal care services … 2. The Plan of Care shall be completed in full to include: … C. Type, frequency & duration of all visits/services ... 5. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration …” P-3: The Start of Care (SOC) was dated 5/1/24. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Diabetes Type 2 and Hypertension. During record review on 10/31/24, it was noted that the Physical Therapy (PT) evaluation dated 5/14/24 stated, “PT 1w1 (1 visit every week for 1 week), 2w1, 1w5.” The PT competed a visit on 5/20/24, 5/22/24 and a discharge on 5/28/24, completing 4 of 9 ordered visits. No physician order or notification was documented. On 5/28/24 the PT documented a discharge visit stating, “Reason for Discharge: No longer meets home health criteria because: Patient’s insurance was changed.” The PT failed to provide the services and frequency as ordered by the physician. This finding was reviewed with and acknowledged by the Staff-A (Administrator) during an interview on 11/6/24 at 10:55 am.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was promptly alerted to a change in the patient’s condition that suggest that outcomes are not being achieved in 1 (P-7) of 7 sample record reviews resulting in the physician being unaware of pertinent patient information and the potential for a poor patient outcome. Findings include: P-7: This 66-year-old was admitted to the agency on 10/22/24 with diagnoses including Osteoarthritis both knees; muscle weakness; high blood pressure; and type 2 Diabetes. The medical record was reviewed on 10/31/24. During review of the plan of care (POC) for the certification period of 10/22/24 through 12/20/24, it was noted under “Orders and Treatments” that agency staff will notify the physician of systolic blood pressure (SBP) readings above 160 and a fasting blood sugar (FBS) above 130. On 10/31/24 a nursing visit note indicated an SBP of 165 and a FBS of 165. The nurse documented a call to the physician regarding medication reconciliation, however, did not document that the physician was informed of, or had any response to the vital signs which were outside of the parameters indicated in the POC. This finding was reviewed and acknowledged on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.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 that skilled services were administered in accordance with the physician’s orders and the Plan of Care in 1 (P-3) of 7 records reviewed, resulting in the potential for decline in physical functioning, unidentified health concerns and unmet care needs. Findings include: P-3: The Start of Care (SOC) was dated 5/1/24. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Diabetes Type 2 and Hypertension. During record review on 10/31/24, it was noted that the POC dated 5/1/24 ordered “Physical Therapy (PT): Evaluate and Treat” The PT evaluation dated 5/14/24 was late by 11 days from the Skilled Nurse (SN) Comprehensive Assessment dated 5/1/24. During the entrance interview on 10/30/24 at 11:30 am, when questioned on the timeframe for additional services to evaluate the patient, Staff A stated, “Within 48 hours.” The agency failed to evaluate the patient within 48 hours. This finding was reviewed with and acknowledged by the Staff-A (Administrator) during an interview on 11/6/24 at 10:55 am.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy services prepared and entered clinical notes per agency expectation in 1 (P-7) of 7 sample records reviewed resulting in a delay of clinical information being available in the medical record. Findings include: P-7: This 66-year-old was admitted to the agency on 10/22/24 with diagnoses including Osteoarthritis both knees; muscle weakness; and high blood pressure. The medical record was reviewed on 10/31/24. During review, it was noted the physical therapist (PT) completed the comprehensive start of care assessment on 10/22/24. It was also noted that a plan of care had not yet been entered for the certification period of 10/22/24 through 12/20/24 (9 days later). Additionally, no PT visit notes were entered after the comprehensive assessment by the PT at the time of record review. It was noted that the medical record contained 3 “Target” PT visits (anticipated visit dates) for 10/24/24, 10/29/24, and 10/31/24. On 10/31/24 a joint home visit was conducted with the Registered Nurse at 11:30 a.m. During interview with P-7, query was made to whether any visits had been made by PT in the last 9 days. P-7 stated that there had been 2 visits since, and one was scheduled for “tomorrow” (11/1/24). On 10/31/24 signage (that was addressed to staff) on the interior door to the agency was observed and stated “Paper Work Due Tuesday 12 Noon NO EXCEPTIONS”. The above findings were reviewed on 11/6/24 during interview with the Administrator (Staff A) at 12:30 p.m. and query was made to expected time frame for staff to complete paperwork and enter it into the medical record. Staff A stated that it is difficult to get staff to comply with the requirement, but it is her expectation that all staff turn in their paperwork including all notes into the electronic medical record each Tuesday by noon as indicated on the signage. Staff A acknowledged that the PT had not turned in their visit notes timely per agency expectations.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the home health aide provided services as ordered by the physician and included in the plan of care for 1 (P-6) of 1 sample records reviewed in which a joint visit with a home health aide occurred, could potentially result in poor patient outcomes. Findings include: P-6: This 84-year-old was admitted to the agency on 9/23/24 with diagnoses including Spondylopathy of spine (disease affecting the spine); Osteoarthritis of the left shoulder; and muscle weakness. The medical record was reviewed on 11/4/24. During review of the home health aide care plan, it was noted that the patient’s activities permitted during aide care included that the patient could get up as tolerated with a cane or walker. On 11/4/24 at 11:10 a.m., a joint visit was conducted with the home health aide. During the visit, the patient was noted to be up and walking around without a cane or a walker. The aide was observed asking the patient where her cane was and a discussion occurred about the patient’s new cane, but the aide did not request that the patient use either the cane or the walker during ambulation at the visit. The patient did not refuse to use the cane or walker during the visit. The aide completed the visit without ever advising the patient to use the cane or the walker while care was being provided. This finding was reviewed and acknowledged on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.m.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to ensure the timely development and implementation of the plan of care per agency expectation in 1 (P-7) of 7 sample record reviews resulting in the medical record lacking pertinent medical information for clinicians to refer to when providing care and the potential for poor patient outcomes. Findings include: P-7: This 66-year-old was admitted to the agency on 10/22/24 with diagnoses including Osteoarthritis both knees; muscle weakness; and high blood pressure. The medical record was reviewed on 10/31/24. During review, it was noted the physical therapist completed the comprehensive start of care assessment on 10/22/24. It was also noted that a plan of care (POC) had not yet been entered into the medical record for the certification period of 10/22/24 through 12/20/24 (9 days later). On 10/31/24 a joint home visit was conducted with the Registered Nurse (RN) at 11:30 a.m. and there was no active POC for the RN to refer to when providing care. This finding was reviewed on 11/6/24 during interview with the Administrator, Staff A at 12:30 p.m. Staff A acknowledged that the expectation for POC development was 48-72 hours after the start of care assessment.”