Classic Home Health Services, Inc.

“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 parameters for 1 of 2 (P-7) records reviewed in which aide services were provided, resulting in a lack of direction regarding the needs of this patient. Findings include: P-7: This 97-year-old patient was admitted to home care on 12/07/23 with diagnoses of type 2 diabetes, recent gastrostomy procedure to insert a feeding tube, and high blood pressure. The patient was receiving enteral tube feedings. During record review on 2/27/24, it was noted that the 12/07/23 plan of care includes the following safety measures: aspiration precautions and elevate head of bed. These two safety measures failed to be included on the 12/7/23 aide care plan which instructed the aide to provide a complete bed bath and shampoo hair each week. The safety measures of aspiration precautions and elevate head of bed are essential safety measures for the aide to implement to ensure the patient does not aspirate tube feedings during the bed bath and shampoo. The findings were reviewed with and acknowledged by the Clinical Manager (CM#1) during an interview on 3/4/24 at 9:50 a.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on document review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status for 7 (P’s #1, 2, 3, 4, 5, 6, 7) records, from a total of 7 sampled records reviewed, resulting in incomplete clinical information needed in determining the needs of these patients and the potential for unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 1/31/24 with diagnoses that included Hypertension, Diabetes Mellitus and Stroke with Left sided weakness. The clinical record review was conducted on 2/27/24 at 2:50 p.m. The Initial Comprehensive Assessment dated 1/31/24 completed by the Registered Nurse revealed the following: Sections 1021/1023 listed primary and other diagnoses of “Essential Hypertension, Generalized Osteoarthritis and Diabetes Mellitus. All the listed diagnoses had an exacerbation date of 1/31/24. There was no history of the listed diagnoses or any continuing needs, and no documentation of the events that lead to the need for home care. The comprehensive assessment failed to paint a clear clinical picture of the patient’s health status at the time of admission or actual identified needs. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 2/28/24 at 11:37 a.m. P-2: The patient’s SOC was 2/9/24 with diagnoses that included Polyosteoarthritis, Pain left shoulder, right leg and lower back. The clinical record review was conducted on 2/28/24 at 9:50 a.m. The Initial Comprehensive Assessment dated 2/9/24 completed by the Physical Therapist revealed the following: Sections 1021/1023 listed primary and other diagnoses as indicated above. All the listed diagnoses had an exacerbation date of 2/9/24. There was no history of the listed diagnoses or any continuing needs, and no documentation of the events that lead to the need for home care. These findings were reviewed with and acknowledged by CM #1 during an interview on 2/28/24 at 11:50 a.m. P-3: The patient’s SOC was 8/10/23 with diagnoses that included Spondylosis of Cervical and Lumbar Region with Myelopathy. The clinical record review was conducted on 2/28/24 at 10:35 a.m. The Initial Comprehensive Assessment dated 8/10/23 completed by the Physical Therapist revealed the following: Sections 1021/1023 listed primary and other diagnoses as indicated above. All the listed diagnoses had an exacerbation date of 8/10/23. There was no history of the listed diagnoses or any continuing needs, and no documentation of the events that lead to the need for home care. These findings were reviewed with and acknowledged by CM #1 during an interview on 2/28/24 at 12:15 p.m. P-4: This 95-year-old patient was admitted to home care on 2/14/24 with diagnoses of hypertensive heart disease with heart failure and osteoarthritis of both knees. During record review on 2/28/24, it was noted that the 2/14/24 comprehensive assessment completed by the registered nurse listed the following primary diagnosis and other diagnoses: hypertensive heart disease with heart failure, bilateral primary osteoarthritis of knee, Type 2 diabetes mellitus without complications, and six additional diagnoses. All listed diagnoses had an exacerbation date of 2/14/24, which is the date of the comprehensive assessment. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. The findings were reviewed with and acknowledged by the Clinical Manager (CM#1) during an interview on 3/4/24 at 9:50 a.m. P-5: This patient was admitted to home care on 2/9/24 with diagnoses of Type 2 diabetes, chronic obstructive pulmonary disease, and burns on the right foot. During record review on 2/27/24, it was noted that the 2/9/24 comprehensive assessment completed by the registered nurse listed the following primary/other diagnoses: Type 2 diabetes with peripheral angiopathy without gangrene, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and nine additional diagnoses. All listed diagnoses had an exacerbation date of 2/9/24, which is the date of the comprehensive assessment. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. P-6: This 100-year-old patient was admitted to home care on 11/13/23 with diagnoses of hypertensive heart and chronic kidney disease with heart failure. During record review on 2/27/24, it was noted that the 11/13/23 comprehensive assessment completed by the registered nurse listed the following primary/other diagnoses: hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, and nine additional diagnoses. All listed diagnoses had an exacerbation date of 11/13/23, which is the date of the comprehensive assessment. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. P-7: This 97-year-old patient was admitted to home care on 12/07/23 with diagnoses of Type 2 diabetes, hypertensive heart disease with heart failure, gastrostomy status (recent gastrostomy procedure to insert a feeding tube), and high blood pressure. During record review on 2/27/24, it was noted that the12/07/23 comprehensive assessment completed by the registered nurse listed the following primary/other diagnoses: Type 2 diabetes mellitus, hypertensive heart disease with heart failure, gastrostomy status, and eight additional diagnoses. All listed diagnoses had an exacerbation date of 12/07/23, which is the date of the comprehensive assessment. The referral paperwork noted that the PEG (percutaneous endoscopic gastrostomy) tube was placed on 11/28/23. It was unclear as to the details of the exacerbation documented by the skilled nurse. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. P-1: The patient’s start of care (SOC) was 1/31/24 with diagnoses that included Hypertension, Diabetes Mellitus and Stroke with Left sided weakness. The clinical record review was conducted on 2/27/24 at 2:50 p.m. The Initial Comprehensive Assessment dated 1/31/24 completed by the Registered Nurse revealed the following: Sections 1021/1023 listed primary and other diagnoses of “Essential Hypertension, Generalized Osteoarthritis and Diabetes Mellitus. All the listed diagnoses had an exacerbation date of 1/31/24. There was no history of the listed diagnoses or any continuing needs, and no documentation of the events that lead to the need for home care. The comprehensive assessment failed to paint a clear clinical picture of the patient’s health status at the time of admission or actual identified needs. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 2/28/24 at 11:37 a.m. P-2: The patient’s SOC was 2/9/24 with diagnoses that included Polyosteoarthritis, Pain left shoulder, right leg and lower back. The clinical record review was conducted on 2/28/24 at 9:50 a.m. The Initial Comprehensive Assessment dated 2/9/24 completed by the Physical Therapist revealed the following: Sections 1021/1023 listed primary and other diagnoses as indicated above. All the listed diagnoses had an exacerbation date of 2/9/24. There was no history of the listed diagnoses or any continuing needs, and no documentation of the events that lead to the need for home care. These findings were reviewed with and acknowledged by CM #1 during an interview on 2/28/24 at 11:50 a.m. P-3: The patient’s SOC was 8/10/23 with diagnoses that included Spondylosis of Cervical and Lumbar Region with Myelopathy. The clinical record review was conducted on 2/28/24 at 10:35 a.m. The Initial Comprehensive Assessment dated 8/10/23 completed by the Physical Therapist revealed the following: Sections 1021/1023 listed primary and other diagnoses as indicated above. All the listed diagnoses had an exacerbation date of 8/10/23. There was no history of the listed diagnoses or any continuing needs, and no documentation of the events that lead to the need for home care. These findings were reviewed with and acknowledged by CM #1 during an interview on 2/28/24 at 12:15 p.m. P-4: This 95-year-old patient was admitted to home care on 2/14/24 with diagnoses of hypertensive heart disease with heart failure and osteoarthritis of both knees. During record review on 2/28/24, it was noted that the 2/14/24 comprehensive assessment completed by the registered nurse listed the following primary diagnosis and other diagnoses: hypertensive heart disease with heart failure, bilateral primary osteoarthritis of knee, Type 2 diabetes mellitus without complications, and six additional diagnoses. All listed diagnoses had an exacerbation date of 2/14/24, which is the date of the comprehensive assessment. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. The findings were reviewed with and acknowledged by the Clinical Manager (CM#1) during an interview on 3/4/24 at 9:50 a.m. P-5: This patient was admitted to home care on 2/9/24 with diagnoses of Type 2 diabetes, chronic obstructive pulmonary disease, and burns on the right foot. During record review on 2/27/24, it was noted that the 2/9/24 comprehensive assessment completed by the registered nurse listed the following primary/other diagnoses: Type 2 diabetes with peripheral angiopathy without gangrene, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and nine additional diagnoses. All listed diagnoses had an exacerbation date of 2/9/24, which is the date of the comprehensive assessment. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. P-6: This 100-year-old patient was admitted to home care on 11/13/23 with diagnoses of hypertensive heart and chronic kidney disease with heart failure. During record review on 2/27/24, it was noted that the 11/13/23 comprehensive assessment completed by the registered nurse listed the following primary/other diagnoses: hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, and nine additional diagnoses. All listed diagnoses had an exacerbation date of 11/13/23, which is the date of the comprehensive assessment. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status. P-7: This 97-year-old patient was admitted to home care on 12/07/23 with diagnoses of Type 2 diabetes, hypertensive heart disease with heart failure, gastrostomy status (recent gastrostomy procedure to insert a feeding tube), and high blood pressure. During record review on 2/27/24, it was noted that the12/07/23 comprehensive assessment completed by the registered nurse listed the following primary/other diagnoses: Type 2 diabetes mellitus, hypertensive heart disease with heart failure, gastrostomy status, and eight additional diagnoses. All listed diagnoses had an exacerbation date of 12/07/23, which is the date of the comprehensive assessment. The referral paperwork noted that the PEG (percutaneous endoscopic gastrostomy) tube was placed on 11/28/23. It was unclear as to the details of the exacerbation documented by the skilled nurse. There was no documentation of the patient’s past medical history or the events that lead to the need for home care services. The skilled nurse failed to ensure the comprehensive assessment provided a complete picture of the patient’s status.”

“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 in 2 (P#’s 2, 3) records, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this Agency. Findings include: Policy: III.8 Comprehensive Assessment and Oasis Data Collection Start of Care stated, “The comprehensive assessment will include, at a minimum: “Review of medications the patient is currently using to identify potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy...” P-2: The patient’s start of care (SOC) was 2/9/24 with diagnoses that included Polyosteoarthritis and Pain Left Shoulder and Lower Back. During the record review on 2/28/24 at 9:50 a.m., it was noted that section M2001 of the Initial Comprehensive Assessment was completed by the Physical Therapist (PT #1) and documented “No issues found during review.” However, the agency’s drug interaction report documented, “Moderate Interactions.” The “Medication Profile” was signed by PT #1. There was no documented evidence that the Registered Nurse (RN) conducted the drug review as per this requirement. 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 Clinical Manager (CM #1) during an interview on 2/28/24 at 11:50 a.m. P-3: The patient’s SOC was 8/10/23 with diagnoses that included Spondylosis of Cervical and Lumbar Region with Myelopathy. The referral for home care dated 8/9/23 ordered Physical Therapy services to be provided. During the record review on 2/28/24 at 10:35 a.m., it was noted that section M2001 of the Initial Comprehensive Assessment was completed by PT #1 and documented “No issues found during review.” A drug interaction report was noted to be dated 8/16/23, the date the patient was discharged from the agency. There was no documented evidence that a drug review had been conducted by an RN at the SOC. These findings were reviewed with and confirmed by CM #1 during an interview on 2/28/24 at 12:15 p.m. who responded, “I instruct the staff to conduct a drug review at the start of care, recertification and at discharge. I don’t see that one was done at the start of care.””

“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 all appropriate interventions, reportable parameters, medications and associated measurable goals for 6 (P#’s 4, 5, 7, 1, 2, 3) records, from a total of 7 sampled records reviewed, resulting in patients not receiving care based on their individualized needs, the potential for poor patient outcomes and unmet care needs. Findings include: Policy: III.7 Professional/Ancillary Care Plans stated, “Each plan will include identified problems and needs, date of onset for each problem, specific individualized measurable goals and interventions...” P-1: The patient’s start of care (SOC) was 1/31/24 with diagnoses that included Diabetes Mellitus, Hypertension and Stroke. During the clinical record review on 2/27/24 at 2:50 p.m., it was noted that the plan of care was void of interventions, reportable parameters in which to notify the Physician and associated measurable goals that addressed the patient’s diagnosis of Diabetes Mellitus. Additionally, all the listed diagnoses had an exacerbation date of 1/31/24, however, there were no interventions to address the diagnoses. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 2/28/24 at11:37 a.m. P-2: The patient’s SOC was 2/9/24 with diagnoses that included Polyosteoarthritis, Pain Left Shoulder, Right Leg and Lower Back. During the clinical record review on 2/28/24 at 9:50 a.m., it was noted that the plan of care was void of reportable pain parameters in which to notify the Physician and associated pain goals. Additionally, the plan of care listed a total of 10 diagnoses with an exacerbation date of 2/9/24. There were no interventions, parameters or associated goals that addressed the listed diagnosis. These findings were reviewed with and acknowledged by CM #1 during an interview on 2/28/24 at 11:50 a.m. P-3: The patient’s SOC was 8/10/23 with diagnoses that included Spondylosis of Cervical and Lumbr Region with Myelopathy. During the clinical record review on 2/28/24 at 10:35 a.m., it was noted that the patient complained of level 7/10 pain on admission. The plan of care was void of any interventions to address pain, reportable parameters in which to notify the Physician and associated pain goals. A Physician’s “Progress Note” dated 8/9/23 documented, “Patient advised to avoid any activities for the present time which may aggravate pain.” This information was not added to the plan of care. Additionally, the plan of care listed 6 diagnoses with an exacerbation date of 8/10/23, however, there were no associated interventions, parameters or goals that addressed the diagnoses. These findings were reviewed with and acknowledged by CM #1 during an interview on 2/28/24 at 12:15 p.m. P-4: This 95-year-old patient was admitted to home care on 2/14/24 with diagnoses of hypertensive heart disease with heart failure and osteoarthritis of both knees. During record review on 2/28/24, it was noted that the 2/14/24 plan of care failed to include measurable skilled nursing goals and outcomes. The plan of care listed the following skilled nursing pain goal: patient/caregiver will verbalize/demonstrate measures to manage pain such as medication management/alternative pain relief measures, behavior modification to avoid factors that increase pain/use of pain scale to identify intensity and determine comfort goal. There was no indication how this skilled nursing goal would be measured to determine the patient’s progress towards discharge. The physical therapy pain goal states the patient will have decreased pain both knees to 0-3/10 (pain scale 0 low -10 high) in 6 weeks. This is a measurable goal. The findings were reviewed with and acknowledged by the Clinical Manager (CM#1) during an interview on 3/4/24 at 9:50 a.m. P-5: This patient was admitted to home care on 2/9/24 with diagnoses of type 2 diabetes, chronic obstructive pulmonary disease, and burns on the right foot. During record review on 2/27/24, it was noted that the 2/9/24 plan of care failed to include the patient’s medications. The 2/9/24 medication profile indicates the patient was on 27 medications that failed to be listed on the plan of care. The plan of care listed the following skilled nursing goals: free of respiratory infection, demonstrate deep breathing/coughing exercises, blood sugar will be within physician established parameters, demonstrate appropriate diabetic skin/foot care. There was no indication how these skilled nursing goals would be measured to determine the patient’s progress towards discharge. P-7: This 97-year-old patient was admitted to home care on 12/07/23 with diagnoses of type 2 diabetes, recent gastrostomy procedure to insert a feeding tube, and high blood pressure. During record review on 2/27/24, it was noted that the 12/07/23 plan of care failed to include interventions regarding enteral tube feedings and failed to include measurable skilled nursing goals. The skilled nursing gastrointestinal intervention documented the following: Enteral feeding bolus/gravity/pump of (blank) amount of (blank) formula at a rate of (blank) verify placement, check residual and flush feeding tube with (blank) cubic centimeters after feeding or medication. This intervention lacked information pertinent to the care and enteral feeding of this patient. The plan of care listed the following skilled nursing goals: enteral feeding tube site will remain intact without signs/symptoms of infection, patient will be able to tolerate feedings without complications, demonstrate appropriate diabetic skin/foot care, and verbalize signs/symptoms of hypo/hyper glycemia, measures to manage, and when to report. There was no indication how these skilled nursing goals would be measured to determine the patient’s progress towards discharge.”

“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 summary was complete, provided the patient’s current health status at the time of discharge and forwarded to the physician within 5 days from the date of discharge from the agency in 1 (P-3) of 2 patients who had been discharged from the agency’s services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health care concerns, lack of continuity of care and unmet care needs. Findings include: Policy: III.11 Discharge Planning, discharge Summary and Discharge Oasis stated, “The discharge summary will include: Admission and discharge dates, Physician responsible, Reason for admission, Reason for discharge, Types of care/services provided, Progress or lack of toward established goals, Patient’s overall status at time of discharge, Any continuing care needs, instructions or referrals...” P-3: The patient’s start of care was 8/10/23 with diagnoses that included Spondylosis of Cervical and Lumbar Region with Myelopathy. During the clinical record review on 2/28/24 at 10:35 a.m., it was noted that the patient was ordered to receive Physical Therapy services. The patient was discharged from the agency on 8/16/23. The “Discharge Summary” dated 8/16/23 was incomplete. The sections titled, Admission date, Discharge date, type of services provided, reason for discharge, condition on discharge, vital signs and care summary were all left blank. Further, there was no indication that the Physician was provided with a copy of a detailed discharge summary within 5 days of the date of the patient’s discharge from the agency’s services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 2/28/24 at 12:15 p.m.”