Allied Home Health Care & Nursing Services

“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 develop an Emergency Preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all 21 patients actively serviced by this Agency in the event of an actual emergency or disaster. Findings include: On 12/4/24 at 1:41 p.m., the agency’s Emergency Preparedness documentation was reviewed with the Clinical Manager (CM #1). During the review, there was no documented evidence that showed the Emergency Preparedness plan had been reviewed/updated at least every 2 years in accordance with the requirements of this section. During the review, CM #1 reported the last update was in 2020. These findings were reviewed with and confirmed by the Clinical Manager at the time of discovery.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure an Emergency Preparedness plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that had been updated at least every 2 years, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 12/4/24 at 1:41 p.m., the agency’s Emergency Preparedness documents were reviewed with the Clinical Manager (CM #1). The Risk Assessment document was dated for the calendar year 2020. The Emergency Preparedness plan had not been updated at least every 2 years, based on a facility and community-based risk assessment from an all-hazards approach. These findings were reviewed with and confirmed by CM #1 at the time of discovery.”

“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 observation, interview and record review, the Agency failed to ensure that 2 (P-1, P-2) of 3 patients observed during home visits, from a total of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 10/15/24 with diagnoses that included Schizoaffective Disorder and Diabetes Mellitus. During the record review on 12/3/24, it was noted that Physical Therapy (PT) and Occupational Therapy (OT) services were ordered to be provided. On 12/3/24 at 9:00 a.m., a scheduled survey home visit was conducted with the OT. During a review of the patient’s admission packet, it was noted that the calendar of proposed visits to be made by the OT and PT was blank. P-2: The patient’s SOC was 7/10/24 with diagnoses that included Cardiomyopathy and Kidney disease with Heart Failure. During the record review on 12/3/24 at 2:40 p.m., it was noted that Skilled Nursing (SN) services were ordered to be provided. On 12/3/24 a scheduled survey home visit was conducted with the SN. During the visit, there was no completed calendar of proposed visits to be made by the SN. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:05 a.m.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-3) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered services. Findings include: P-3: The patient’s start of care was 12/19/23 with diagnoses that included Parkingson’s Disease, Diabetes Mellitus and COPD (Chronic Obstructive Pulmonary Disease). The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 12/4/24 at 9:50 a.m., it was noted that the patient was discharged from the agency’s services on 2/15/24. The “Notice of Medicare Non-Coverage” was provided to and signed by the patient on the same date of 2/15/24, which was the same date of the patient’s discharge from the agency’s services. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:30 a.m.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 1 (P-1) record reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for decline in health status and unmet care needs. Findings include: P-1: The patient’s start of care was 10/15/24 with diagnoses that included Depression, Schizoaffective Disorder and Diabetes Mellitus. During the record review on 12/3/24, it was noted that the referral for home care was dated 10/10/24 and ordered Physical Therapy and Occupational Therapy services to be provided. Upon further review, it was noted that the SOC was delayed by 5 days. Further, there was no documented justification for the delay in needed care and services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 9”36 a.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) 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: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status and included the events leading to the need for home care services in 2 (P-1, P-3) records, from a total of 7 sampled records reviewed, resulting in incomplete/inaccurate clinical information to aide in determining the needs of the patient. Findings include: P-1: The patient’s start of care (SOC) was 10/15/24 with diagnoses that included Depression, Schizoaffective Disorder and Diabetes Mellitus. During the review on 12/3/24, it was noted that section M1021 of the Initial Comprehensive Assessment dated 10/15/24, listed 16 diagnoses with an onset of 1010/24. There was no documented history of the identified illnesses. Additionally, Section M2001 stated, “No issues found during review.” However, the agency’s Drug Interaction Report documented positive drug to drug interactions. The Comprehensive Assessment failed to paint an accurate clinical picture of the patient’s health status at the time of admission. P-3: The patient’s SOC was 12/19/23 with diagnoses that included Parkinson’s Disease, Diabetes Mellitus and COPD. During the record review on 12/4/24 at 9:50 a.m., it was noted that section M1021 of the comprehensive Assessment dated 12/19/23, listed 13 diagnoses all having an onset date of 10/13/23. There was no documented history or resolution of the listed diagnoses. The Comprehensive Assessment failed to paint an accurate clinical picture of the patient’s health status at the time of admission. The above findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:30 a.m.”

“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 record review and interview, 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 who required assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, lack of self-esteem and unmet care needs. Findings include: P-3: the patient’s start of care was 12/19/23 with diagnoses that included Parkinson’s Disease, Diabetes Mellitus and COPD. During the record review on 12/4/24 at 9:50 a.m., it was noted that section M1800 (Grooming) of the Initial Comprehensive Assessment dated 12/19/23 documented, someone must assist with grooming, dressing, bathing, toileting. There was no documentation of a willing caregiver and no documented evidence that a Home Health Aide was offered or provided to assist with activities of daily living. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 12/5/24 at 10:30 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 the discharge summaries were complete and detailed the course of care provided, including progress toward goals and failed to ensure the summaries were forwarded to the Physician within 5 days of the date of discharge for 2 (P-3, P-5) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in the Physician not having a clear picture of the health status of the patient at the time of discharge and the potential for unmet continuing care needs. Findings include: P-5: The start of care (SOC) was dated 3/22/23, with diagnoses of surgical aftercare and spinal fusion. During record review on 12/3/24, it was noted that the record contained a skilled nursing discharge summary dated 11/30/23. The discharge summary failed to include progress towards, and patient outcomes in meeting the goals in the plan of care. These findings were reviewed and acknowledged during an interview with the clinical manager (CM #1) on 12/5/24 at 2:50 p.m. P-3: The patient’s start of care was 12/19/23 with diagnoses that included Parkinson’s Disease, Diabetes Mellitus and COPD. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 12/4/24 at 9:50 a.m., it was noted that the patient was discharged from PT services on 1/26/24. The patient was discharged from SN services on 1/31/24 and discharged from OT services on 2/15/24. The SN Discharge Summary dated 1/31/24, was void of a summary of care with responses and overall health status at the time of discharge. Further, there was no indication of which, if any, goals were met versus not met. Additionally, there was no documented evidence that the summary was forwarded to the Physician within 5 days of the date of discharge. The patient was discharged from OT and the agency’s services on 2/15/24. There was no documented evidence that the OT Discharge Summary was forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:30 a.m.”