Aquarius Home Care, LLC

“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-1) 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-1: The patient’s start of care (SOC) was 1/11/24 with diagnoses that included Heart Failure and Coronary Artery Disease. On 2/6/24 at 11:00 a.m., a joint survey home visit was conducted with the Registered Nurse (RN #1). During the visit, RN #1 assessed the vital signs (blood pressure, temperature, oxygen saturation, bowel sounds and peripheral edema and pulses). After checking the patient’s blood pressure, RN #1 placed his stethoscope around his neck. RN #1 did not clean his equipment prior to placing it around her neck. RN #1 then placed the unit used to check the patient’s oxygen level, as well as the blood pressure equipment and thermometer in his work bag without sanitizing the equipment first. It was further noted that RN #1 donned a pair of gloves at the beginning of the visit and kept the same gloves on until the conclusion of the visit. RN #1 failed to utilize Infection Control standards of practice during the provision of care. Upon completion of the visit, RN #1 acknowledged the above observations. These findings were reviewed with and acknowledged by the Administrator and Alternate Administrator during an interview on 2/7/24 at 1:17 p.m. These findings were revi”

“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 3 (P’s #1, 2, 3) of 3 patients observed during home visits were included in the overall planning of their care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 7 sampled records reviewed, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 1/11/24 with diagnoses that included Coronary Artery Disease and Heart Failure. During the record review on 2/5/24 at 1:55 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provide. On 2/6/24 during a scheduled survey home visit with the Registered Nurse (RN #1), it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by SN or any of the other ordered disciplines. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 2/7/24 at 1:17 p.m. P-2: The patient’s SOC was 12/15/23 with diagnoses that included Diabetes Mellitus and Congestive Heart Failure. During the record review on 2/6/24 at 2:55 p.m., it was noted that the POC ordered SN, PT and Occupational Therapy (OT) services to be provided. On 2/6/24 during a scheduled survey home visit with the Physical Therapist (PT #1), it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by any of the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/7/24 at 1:26 p.m. P-3: The patient’s SOC was 1/12/24 with diagnoses that included Multiple Sclerosis and Hemiplegia. During the record review on 2/7/24 at 9:55 a.m., it was noted that the POC ordered SN, PT and OT services to be provided. On 2/7/24 during a scheduled survey home visit with the Occupational Therapist (OT #1), it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by any of the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/7/24.”

“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 2 (P#’s 2, 3) patients observed during home visits and required assistance with grooming, from a total of 7 sampled patients reviewed, resulting in the potential for poor hygiene, low self-esteem and unmet care needs. Findings include: Policy: Patient Admission Criteria, 9.3.1 stated, “Patients are accepted for treatment on the basis of a reasonable expectation that the patient’s medical, nursing and social needs can be met adequately by the Agency in the patient’s place of residence. Patients will be accepted for care only if Agency can meet a patient’s identified needs.” P-2: The patient’s start of care (SOC) was 12/15/23 with diagnoses that included Diabetes Mellitus, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. On 2/6/24 at 12:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). Upon arrival, the patient was noted to be lying in bed, obese and bedbound. During the visit, PT #1 attempted to assist the patient with standing, however, the patient reported that it was too painful and difficult to stand. When the visit was completed, the patient was queried as to how she was able to groom and dress herself to which she replied, “My granddaughter helps me out sometimes when she’s free.” The patient then stated, “I wanted a home health aide but the last time I was with the agency, the aides did what they wanted to do. I could really use an aide. I had to hire a private caregiver when the agency didn’t send one, but usually I just wait on my granddaughter. I only chose to come back to this agency because I like the therapist.” During the record review on 2/6/24 at 2:55 p.m., section M1800 of the Comprehensive Assessment documented that someone must assist the patient to groom and dress self and depends entirely upon another person to dress lower body. Section M2102 documented, “Non-agency caregivers need training/supportive services to provide assistance.” On 2/7/24 at 1:26 p.m., an interview was conducted with the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1). When queried about the provision of Home Health Aide services, Adm #2 responded, “We had her as a patient last time and she (patient) requested the aides add bleach to her bath water. The patient is aware that we cannot bathe her with bleach. She’s trying to make trouble for us. If we cannot provide the service, we would drop the patient.” An article by the Mayo Clinic documented, “A bath with a small amount of bleach added to the water is safe for children and adults..., helps reduce bacteria on the skin..., helps reduce inflammation.” Further review revealed no documented evidence that the patient’s Physician had been consulted regarding her request to add bleach to her basin during bathing. P-3: The patient’s SOC weas 1/12/24 with diagnoses that included Multiple Sclerosis, Scoliosis and Hemiplegia. During the record review on 2/7/24 at 9:55 a.m., it was noted that the comprehensive assessment listed the patient’s son as the primary caregiver and stated, “patient lives alone with occasional short-term assistance, non-agency caregivers need training/supportive services to provide assistance, someone must assist with grooming, depends entirely upon another person to dress upper and lower body, unable to participate effectively in bathing and is bathed totally by another person, totally dependent in toileting, chairfast, unable to ambulate and is unable to wheel self...” On 2/7/24 at 11:00 a.m., a scheduled joint survey home visit was conducted with the Occupational Therapist (OT #1). Prior to entering the patient’s unit, OT #1 informed the writer that the patient is supposed to have a private caregiver, if they decide to come. Upon entering, the patient was observed sitting in her motorized wheelchair. She was Mal positioned due to her diagnosis of scoliosis (abnormal curvature of the spine). The patient’s clothes were baggy and twisted around her waist and she appeared ungroomed. During the visit, the patient stated, “The caregiver was supposed to come. She missed the last time. I wish I had more people who could help me. I just keep the same clothes on, even at night. My sister has 8 grandchildren, and my son is immature and told me, “20 years of helping you Mother is quite a bit.” There was no documented evidence that the patient had been offered the services of a home health aide to assist with activities of daily living. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/7/24.”

“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 observation, record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications at the start of care and the resumption of care, in 3 (P#’s 3, 5, 7) records, in order to determine any untoward effects, 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: Policy: Medication Profile, 11.8.1 stated, “The comprehensive assessment (OASIS) performed at time of admission includes a review of all medications that 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, duplicative drug therapy and noncompliance with drug therapy..., All prescribed medications, over-the-counter (OTC) medications and home remedies will be documented on the medication profile as well as...” P-3: The patient’s start of care (SOC) was 1/12/24 with diagnoses that included Multiple Sclerosis and Hemiplegia. On 2/7/24 at 11:00 a.m., a scheduled survey home visit with the Occupational Therapist (OT #1). During the conversation with the patient and OT #1, the patient stated, “I take so many supplements, I couldn’t possible catch covid. When looking at the patient’s plan of care (POC), it was noted that only 3 medications were listed. This writer asked the patient if she was taking anymore medications to which she pointed at a plastic shelf with multiple drawers and stated, “Some of my medications are in there.” The patient then gave permission to review her medications. Upon review, there were multiple bottles of supplements, laxatives, vitamins, melatonin, creatine, probiotics and more. There were 34 bottles of medications in the drawers. Additionally, there was a Ziploc bag with pills and what appeared to be additional supplements, and there was a small tray of medications observed next to the patient’s bathroom. None of the aforementioned medications had been listed on the patient’s POC. The agency failed to conduct a comprehensive review of all the patient’s medications at the start of care. These findings were reviewed with the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 2/7/24. During the interview, Adm #1 stated, “We have had that discussion with RN #1 because that has been a problem.” There was no documented evidence that justified RN #1’s failure to conduct a comprehensive drug review of all the patient’s medications. P-5: The patient’s SOC was 3/10/23 with diagnoses that included Diabetes Mellitus and Chronic Obstructive Pulmonary disease. During the record review on 2/7/24, there was no evidence that a comprehensive drug review had been conducted at the SOC. Further review revealed the patient was transferred to an inpatient facility on 3/18/23 due to abdominal pain and resumed care with the agency’s services on 3/22/23. There was no documented evidence that a comprehensive drug review was conducted upon resumption of care to the agency’s services. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/8/24. P-7: The patient’s SOC was 2/2/24 with a diagnosis of Osteoarthritis. During the drug review on 2/8/24 at 12:05 p.m., there was no documented evidence that a comprehensive drug review had been conducted. These findings were reviewed with and acknowledged by Adm #1 during an interview on 2/8/24.”

“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 covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient and failed to ensure all prescribed medications had been included in the plan of care, for 3 (P’s #1, 2, 4) of 3 records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs, the potential for decline in overall health and poor patient outcomes. Findings include: P-1: The patient’s start of care (SOC) was 1/11/24 with diagnoses that included Heart Failure and Coronary Artery Disease. During the record review on 2/5/24 at 1:55 p.m., it was noted that the plan of care (POC) was void of any interventions, reportable parameters or associated measurable goals to address the identified diagnoses. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 2/7/24 at 1:17 p.m. P-2: The patient’s SOC was 12/15/23 with diagnoses that included Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. During the clinical record review on 2/6/24 at 2:55 p.m., it was noted that the POC was void of any interventions, reportable parameters or associated measurable goals to address the identified diagnoses. Further review of the record revealed the patient was transferred to an inpatient hospital on 12/24/23 due to shortness of breath. Care was resumed under the agency’s services on 1/8/24. The record revealed the patient returned home from the hospital with a Stage III coccyx pressure sore. The agency failed to update the plan of care to reflect the patient’s current diagnosis, needs and treatment regimen. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/8/24 at 10:43 a.m. P-4: The patient’s SOC was 2/15/23 with diagnoses that included Congestive Heart Failure, Hypertensive Heart Disease and Diabetes Mellitus. During the clinical record review conducted on 2/7/24, it was noted that the POC was void of interventions, parameters, teaching and measurable goals that addressed the patient’s identified diagnoses. These findings were reviewed with and acknowledged by Adm #1 during an interview on 2/8/24 at 9:29 a.m. who reported, “The plan of care could be done better.””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, interview and record review, the agency P-2: The patient’s SOC was 12/15/23 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. During the clinical record review on 2/6/24 at 2:55 p.m., it was noted that the Initial Comprehensive Assessment had a baseline documented weight of 410 pounds (lbs.). It was not clear if this was an actual or stated weight. A review of the Skilled Nursing Visit Notes documented the following: 12/15/23 410 lbs., 1/8/24 410 lbs. “actual weight”, 1/17/24, no documented weight, 1/24/24 no documented weight, 2/2/24 no documented weight. On 2/6/24 at 12:30 p.m. a scheduled survey home visit was conducted with the Physical Therapist. The patient was observed to be obese and bedbound with limited mobility and observed to have difficulty when attempting to stand for PT session. A Hoyer lift (transfer aid) was observed at the foot of the patient’s bed. On 2/8/24 at 9:20 a.m., the Alternate Administrator (Adm #2) was asked what method was used to assess the patient’s weights, in light of her diagnosis of Congestive Heart Failure. Adm #2 reported, “I don’t know if he (RN #1) is weighing her. When asked what method was used to ascertain the patient’s fluid level and to determine if there was a weight gain, Adm #2 was unable to respond. Adm #2 continued, “I think that weight (410) came from the hospital records. I think that’s why he (RN #1) put “actual.” There was no other documentation in the clinical record that indicated the patient’s weights were assessed in light of her admitting diagnoses. The agency failed to ensure its skilled disciplines performed accurate baseline and ongoing assessments of the patient’s weight and health status.”

“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 services were provided as ordered by the Physician for 1 (P-1) patient who required Occupational Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for physiological decline and unmet care needs. Findings include: P-1: The patient’s start of care was 1/11/24 with diagnoses that included Coronary Artery Disease, Heart Failure and Falls. During the record review on 2/5/24 at 1:55 p.m., it was noted that the referral for home care ordered Occupational Therapy (OT), Physical Therapy (PT) and Skilled Nursing (SN) services to be provided. Further review revealed that Occupational Therapy services had not been provided. Additionally, there was no documented evidence that the patient declined services or that the Physician had been made aware that services were not provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 2/7/24 at 1:17 p.m. Adm #2 reported, “This service was not provided. I don’t think we had anyone available. I think the patient had bugs but I didn’t document anything. I think the Physician ended up only ordering PT and SN.””

“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 insure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 (P#’s 4, 5) discharge records reviewed; and failed to ensure a detailed transfer summary was sent to the receiving health care facility within 2 business of becoming aware of the transfer for 1 (P-2) patient who was transferred to an inpatient facility, from a total of 7 sampled records reviewed, resulting in a lack of continuity of care and the potential for unmet care needs. Findings include: Policy 9.31.1 stated, “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. The original Discharge Summary form from each service will be filed in the medical record.” Policy: Transfer/Referral Criteria 9.29.1 stated, “A written Transfer Summary concerning the Agency’s involvement with the patient, e.g., summary of care/services provided, patient’s current physical and psychosocial status, instructions/referrals provided to patient, current reconciled medication list (with an explanation of how to obtain clarification), advance directives, any continuing symptom management needs, e.g., pain, nausea or dyspnea, and reasons for transfer or referral will be completed. Transfer Summary will be provided: - Within two business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or - Within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time the Agency becomes aware of the transfer.” P-4: The patient’s start of care was 2/15/23 with diagnoses that included Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 2/7/24, it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The patient was discharged from PT services on 3/21/23 and discharged from SN services on 3/29/23. Upon further review, there was no documented evidence that the Discharge Summaries were sent to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 2/8/24 at 9:29 a.m. P-5: The patient’s SOC was 3/10/23 with diagnoses that included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and Hypertension. During the record review on 2/7/24, it was noted that the referral for home care ordered OT, PT, SN and Home Health Aide (HHa) services to be provided. Speech Therapy (ST) and Medical Social Work (MSW) were added services to be provided. The patient was discharged from MSW on 4/18/23, ST on 4/20/23, OT on 4/26/23, PT on 4/27/23 and SN on 5/3/23. No ST Discharge Summary had been completed at the time of this review. Adm #2 provided a Fax cover sheet which indicated all Discharge Summaries were sent to the Physician on 5/12/23. This was greater than 5 days after the date of discharge from each service. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and the Clinical Manager (CM #1) during an interview on 2/8/24 at 11:10 a.m. P-2: The patient’s SOC was 12/15/23 with diagnoses that included Diabetes Mellitus, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. During the clinical record review on 2/6/24 at 2:55 p.m., it was noted that the patient was transferred to an inpatient facility due to shortness of breath. The Transfer Oasis/Comprehensive Assessment was completed 4 days later on 12/28/23. Upon further review, there was no documented evidence that a transfer summary had been sent to the receiving facility within 2 days of becoming aware of the transfer. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/8/24 at 10:42 a.m. Adm #2 reported, “We sent them (documents) to the Physician, but we didn’t send anything to the receiving facility.””