Honest Home Care, Inc.

“Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient’s immediate care needs in 2 records (P-2, P-7) from a total of 7 records reviewed, resulting in the potential for unmet care needs for all 14 patients currently receiving services. Findings include: P-2: The start of care (SOC) date for this patient was 11/22/2023, with diagnoses which included diabetes-type 2, osteo-arthritis, and hypertension. The referral for home care (11/22/23) noted under “Chief Complaint” that P-2 “complains of blurred vision and retinopathy... Blood sugars will run up to 300’s at night and she will frequently take another dose of insulin at that time.” On 2/13/24, review of the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had revealed the following concerns. Under “Endocrine” (used for assessing diabetes), SN had checked ten interventions which were to be performed that day (SN discharged P-2 on 11/22/23) from SN service. In addition, SN documented goals for P-2’s blood sugar readings were to be between 70 mg/dl. and 350 mg/dl. during the certification period. SN also documented under “Conclusions” that “Skilled Intervention” and “Skilled Instruction” were needed. However, no documentation was found within the initial assessment of SN ever performing any of the 10 interventions listed for diabetes. Further, under “Skilled Intervention” the entire narrative section that details what SN performed during the initial assessment was void of any diabetic information. Under “Plan for Next Visit”, SN documented, “Teach about Diabetes Mellitus-the risk factors and treatment.” No evidence was found in the medical record this occurred while P-2 was admitted by the agency. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:05 PM. Both agreed this did not meet agency expectations or its policy referenced below. Agency Policy: “Comprehensive Client Assessment” (undated) stated, “The depth and frequency on ongoing assessments will depend on client needs, goals, and the care treatment and services provided... Reassessments are conducted based on client needs, physician orders...” P-7: The SOC date for this patient was 11/30/2023, with diagnoses which included osteo-arthritis, congestive heart failure (CHF), urinary tract infection (UTI), and bacterial pneumonia. The referral for home care (11/29/23) documented P-7’s weight was 125 pounds on 11/27/23 at 11:51 AM. Under Assessment/Plan, the physician documented “daily walking program, daily weight check, pt. needs visiting nurse.” In addition, under “Problems” the referral listed 25 diagnoses including 10 different onset dates, such as CHF/fluid overload occurring on 2/27/2020, 9/9/2023, and again on 10/19/23. However, the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had documented only 8 diagnoses, all with dates of onset being 11/30/23. P-2 also had an active UTI and bacterial pneumonia listed under the referral’s “Assessment/Plan” on 11/29/23. On 2/14/24, review of the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had documented a “stated” weight of 130 pounds. SN under “Notify Physician of:” left then section concerning weight greater (>) or less than ( These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:35 PM. Both agreed this did not meet agency expectations or its policy referenced above.”

“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, it was determined the agency failed to ensure the plan of care (POC) met the needs of the patient in 3 (P-2, P-3, and P-7) of 7 records, out of a total sample of 7 records reviewed, resulting in the potential for negative patient outcomes for all 14 patients currently receiving services. Findings include: P-2: The start of care (SOC) date for this patient was 11/22/2023, with diagnoses which included diabetes-type 2, osteo-arthritis, and hypertension. The referral for home care (11/22/23) noted under “Chief Complaint” that P-2 “complains of blurred vision and retinopathy... Blood sugars (BS) will run up to 300’s at night and she will frequently take another dose of insulin at that time.” On 2/13/24, review of the POC revealed no orders to assess and document P-2’s BS readings. Subsequently, 6 of 6 visits (11.24.23 to 12.13.23) made by the lone discipline of physical therapy failed to document any aspects concerning P-2’s diabetes throughout admission. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 3:50 PM. Both agreed this did not meet agency expectations or its policy referenced below. Agency Policy: “Care Plans” (undated) pg. 1 stated, “Each client will have a care plan on file that outline care and services necessary to meet the patient specific needs identified...” P-3: The SOC date for this patient was 1/18/23, with diagnoses which included diabetes-type 2, hypertensive heart disease with congestive heart failure (CHF), and chronic kidney disease. On 2/13/24, review of the initial SOC assessment found P-3’s blood sugar (BS) was 312 mg/dL. (normal is 74-106). The next visit on 1/25/23, skilled nursing (SN) had documented the following: “SN checked the BS level, first reading was 529 mg/dL., patient/cg stated she just ate breakfast, she had cereal with milk and some coffee. SN administered Victoza (medication for blood sugar control) 6 units and the re-checked BS after 30 minutes and went down to 429 mg/dL. SN instructed patient/cg to take the patient to the hospital, but patient and cg refused.” When the Plan of Care (POC) for P-3 was reviewed, an order for Victoza was noted for a subcutaneous injection of 6 units daily. However, no sliding-scale insulin coverage was found in P-3’s POC, and no order was found which authorized SN to administer any amount of Victoza PRN (as needed) under any circumstances. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:10 PM. Both agreed the POC should have included an order for sliding-scale insulin coverage prior to the 1/25/23 visit given P-3’s previous diabetic history. The POC failed to include patient specific treatments/interventions to meet the needs of the patient. P-7: The SOC date for this patient was 11/30/2023, with diagnoses which included osteo-arthritis, congestive heart failure (CHF), urinary tract infection (UTI), and bacterial pneumonia. The referral for home care (11/29/23) documented P-7’s weight was 125 pounds on 11/27/23 at 11:51 AM. The SOC assessment documented the patient’s weight increased to 130 pounds. The referral’s “Assessment/Plan” noted the physician documented for “daily walking program, daily weight check, pt. needs visiting nurse.” In addition, under “Problems” the referral noted significant history of CHF/fluid overload occurring on 2/27/2020, 9/9/2023, and again on 10/19/23. On 2/14/24, review of P-7’s plan of care (POC) failed to have any detailed patient specific treatments/interventions for CHF. Subsequently no other weight assessments were performed until 1/26/24, when P-2 was being recertified for another episode by physical therapy (PT) services. PT documented P-2’s “stated” weight as 158 pounds (gain of 33-pounds since 11/27/23). Further, after the SOC assessment by skilled nursing (SN) on 11/30/24, the POC failed to incorporate any further SN visits to help meet the patient’s needs as noted by the physician referral above. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:35 PM. Both agreed the POC for P-7 did not meet agency expectations or its policy referenced above.”

“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 agency failed to ensure services were provided only as ordered by the physician in 1 (P-3) of 7 total records reviewed, resulting in the potential to negatively affect all 14 patients currently serviced by the agency. Findings include: P-3: The start of care (SOC) date for this patient was 1/18/23, with diagnoses which included diabetes-type 2, hypertensive heart disease with congestive heart failure (CHF), and chronic kidney disease. On 2/13/24, review of the initial SOC assessment found P-3’s blood sugar (BS) was 312 mg/dL. (normal is 74-106). The next visit on 1/25/23, skilled nursing (SN) had documented the following: “SN checked the BS level, first reading was 529 mg/dL., patient/cg stated she just ate breakfast, she had cereal with milk and some coffee. SN administered Victoza (medication for blood sugar control) 6 units and the re-checked BS after 30 minutes and went down to 429 mg/dL. SN instructed patient/cg to take the patient to the hospital, but patient and cg refused.” It was unclear from the 1/25/23 note if P-3 had already taken the daily dose of Victoza prior to SN’s administration. Further review of the SN notes on 1/25/23 found the physician’s office was contacted concerning the “elevated blood sugar” but no documentation of subsequent orders or physician response was found in the medical record. When the Plan of Care (POC) for P-3 was reviewed, an order for Victoza was noted for a subcutaneous injection of 6 units daily. However, no sliding-scale insulin coverage was found in P-3’s POC, and no order was found which authorized SN to administer any amount of Victoza PRN (as needed) under any circumstances. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:10 PM. Both agreed SN should not have administered Victoza and should have obtained an order for sliding-scale insulin coverage prior to the 1/25/23 visit given P-3’s previous diabetic history.”

“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 notified of changes in the patient’s condition in 1 (P-7) of 7 records reviewed from a total sample of 7 records, resulting in the potential for poor clinical outcomes for all 14 patients currently receiving services. Findings include: P-7: The SOC date for this patient was 11/30/2023, with diagnoses which included osteo-arthritis, congestive heart failure (CHF), urinary tract infection (UTI), and bacterial pneumonia. The referral for home care (11/29/23) documented P-7’s weight was 125 pounds on 11/27/23 at 11:51 AM. In addition, the referral noted the primary diagnosis as CHF/fluid overload, with occurrences on 2/27/2020, 9/9/2023, and again on 10/19/23. The referral’s “Assessment/Plan” section documented daily weight checks were warranted to monitor for fluid overload. On 2/14/24, review of the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had documented a “stated” weight of 130 pounds. No other weight assessments were performed until 1/26/24, when P-2 was being recertified for another episode by physical therapy (PT) services. PT documented P-2’s “stated” weight as 158 pounds (gain of 33-pounds since 11/27/23), indicating the potential for fluid overload with subsequent hospitalization as evidenced from the three previous occurrences noted above. No evidence was found which indicated PT was aware of the significance of this weight gain, and no physician notification was found in the medical record. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:35 PM. Even though the recertification assessment on 1/26/24 showed no cardiovascular or respiratory concerns, both agreed the PT should have notified the physician once an actual weight was obtained.”

“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, it was determined that the agency failed to provide documentation that a discharge summary had been sent to the physician for review as required in 3 (P-2, P-3, and P-6) of 3 discharge records, out of a total sample of 7 records reviewed, resulting in the potential for unmet post-discharge needs. Findings include: P-2: This patient was admitted to the agency on 11/22/2023, with diagnoses which included diabetes-type 2, osteo-arthritis, and hypertension. The referral for home care (11/22/23) noted under “Chief Complaint” that P-2 “complains of blurred vision and retinopathy... Blood sugars will run up to 300’s at night and she will frequently take another dose of insulin at that time.” On 2/13/24, record review noted skilled nursing (SN) had performed a discharge from SN services on 11/22/23, the same day P-2 was admitted. Physical therapy (PT) had discharged the patient from the agency on 12/13/23. However, evidence of a discharge summary from the agency was not found in the medical record. No summary of findings concerning P-2’s diabetes management was provided to the physician for review. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 3:45 PM. Both agreed this did not meet agency expectations or its policy referenced below. Agency Policy: “Discharge Policy & Summary” (undated) stated, “The discharge summary shall include, but not limited to: Services provided; Status upon admission; Status at time of discharge, Patient response to treatment...” The policy further stated, “When a client is discharged from the agency, a discharge summary and/or OASIS (Outcome and Assessment Information Set) form shall be completed... A copy of the discharge summary will be sent to the physician...” P-3: The admit date for this patient was 1/18/23, with diagnoses which included diabetes-type 2, hypertensive heart disease with congestive heart failure (CHF), and chronic kidney disease. The referral for home care (1/18/23) documented that P-2 had 13 diagnoses concerning: “Uncontrolled systolic blood pressure around 185... acute diastolic CHF exacerbation, discharged from the hospital 8/8 cont bumex (diuretic medication) ...” (SIC) and being an insulin-dependent diabetic. On 2/13/24, record review found the patient had been hospitalized on 2/15/23 due to uncontrolled blood sugars greater than 500 (normal is 74-106). Further review noted SN discharged the patient from the agency on 3/16/23. SN utilized the OASIS discharge form which included a “Discharge Summary” that failed to summarize any of the medical concerns above with clinical data obtained throughout the certification period, response to intervention/treatments, and progress made towards set goals. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:00 PM. Both agreed this did not meet agency expectations or its policy referenced above. P-6: The admit date for this patient was 7/11/23, with diagnoses which included cerebral infarction (stroke in the brain), dysphagia (difficulty swallowing), and low back pain. On 2/14/24, record review noted PT (lone discipline ordered) discharged the patient from the agency on 8/2/23. Additional review found no evidence of a discharge summary in the medical record. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:15 PM. Both agreed this did not meet agency expectations or its policy referenced above.”