Magic Home Care, LLC

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled discipline provided care and services in accordance with the visit frequency as ordered by the Physician and the plan of care for 2 (P-2, 5) patients who required Skilled Nursing/Physical Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns and unmet care needs. Findings include: Policy: “Plan of Care - CMS #485”, 2/2023 stated, “Each patient must receive the home health services that are written in an individualized plan of care..., Care and services provided will be provided according to Physician/Practitioner orders...” P-2: The patient’s start of care was 9/23/24 with diagnoses which included Hypertensive Heart Disease with Heart Failure and diabetes Mellitus. During the record review on 10/15/24 at 10:00 a.m., it was noted that the plan of care ordered Skilled Nursing (SN) services to be provided at a frequency of 2x/wk. x 2 wks., 1x/wk. x 7wks. During the second week of care beginning 9/29/24, the SN only made 1 of the 2 ordered visits to the patient’s home. There was no missed visit note, no documented rationale as to why the visit was missed, and no documented evidence that the Physician had been notified. These findings were reviewed with and acknowledged by the Admission Coordinator during an interview on 10/16/24 at 2:28 p.m. P-5: The patient’s start of care was 8/26/24, with diagnoses of hypertension and chronic kidney disease. During record review on 10/15/24, it was noted that the plan of care (POC) ordered Skilled Nursing (SN) services at a frequency of 2 visits a week for 2 weeks, and 1 visit a week for 7 weeks. Physical therapy (PT) was ordered at a frequency of 1 visit a week for 1 week, and 2 visits a week for 8 weeks. There were no documented PT visits for the 7th week of service. There was no missed visit note or communication with the physician documented in the record. The Admission Coordinator (AC #1) acknowledged the findings during an interview on 10/17/24 at 11:15 a.m.”

“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, it was determined the Agency failed to provide documented evidence that Infection Control in-services and education provided to all staff employed by this agency, including all contracted staff who were granted clinical privileges, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency. Findings include: On 10/15/24 at 10:45 a.m., as requested, a list of staff who received training/in-services in Infection Control was provided. The Office Manager (OM #1) stated, “These are all the employees who were present at the time.” When asked if contracted staff received training in infection control, OM #1 inquired, “wouldn’t that be the responsibility of the staffing agency?” When asked if there was documented evidence that the staffing agency had provided training/education in infection control, OM #1 offered no response. On 10/16/24 at 12:05 p.m., a comparison of employed/contracted staff was made with the list of attendees who received infection control training during the last reported in-service on 9/27/24. There was no documented evidence that those who were granted clinical privileges (contracted staff) had received training in infection control as per this requirement. These findings were reviewed with and acknowledged by OM #1 at the time of discovery and again with the Admission Coordinator during a subsequent interview on 10/16/24.”

“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, it was determined skilled nursing failed to prepare clearly written patient care instructions and include safety measures on the aide’s care plan in 1 of 1 records reviewed in which Home Health Aide services were provided (P-4), from a total sample of 7 records reviewed, resulting in the potential for injuries and the provision of unsafe care during aide services. Findings include: P-4-: The SOC was 5/27/24, with diagnoses of spondylosis, osteoporosis, and difficulty walking. The POC included orders for the following visit frequencies: Skilled Nursing (SN), Physical Therapy (PT), and Home Health Aide (HHa). The following POC safety precautions were noted during review on 12/8/20: “Diabetes, Fall precautions, universal precautions...” During record review on 10/14/24, the “Aide Care Plan” dated 5/27/24, completed by skilled nursing, failed to include any safety precautions. During an interview on 10/17/24 at 11:15 a.m., the Admission Coordinator (AC #1) acknowledged the above findings.””

“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 1 (P-1) of 2 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 start of care was 9/30/24 with diagnoses that included Essential Hypertension and Myalgia. During the record review on 10/15/24 at 12:00 p.m., it was noted that Skilled Nursing and Physical Therapy services were ordered to be provided. On 10/14/24 at 12:30 p.m., a scheduled survey home visit was conducted with the Physical Therapy Assistant. During the visit, a review of the patient’s admission packet revealed a blank calendar of what was to contain a schedule of proposed visits to be made by the ordered disciplines. Upon completion of the visit, PTA #1 was asked how the patient/caregivers would be made aware of any future visits, to which she replied, “I come out to this area on Mondays, Wednesdays and Fridays and I go to Oak Park on my even days. That’s what works best for me. It’s the only way I could do this.” The agency failed to ensure a calendar of proposed visits had been provided at the start of care to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Admissions Coordinator during an interview on 10/16/24 at 2:15 p.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 observation, record review and interview, the agency failed to ensure the patient’s Physical Therapy needs were adequately met in the home for 1 (P-2) patient observed during a home visit, who required assistance with mobility, from a total of 7 sampled records reviewed, resulting in the potential for further decline in physiological health. Findings include: P-2: The patient’s start of care was 9/23/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure and diabetes Mellitus. On 10/14/24 at 2:30 p.m., a scheduled survey home visit was conducted with the nurse (RN #1). The patient was observed lying in bed. During the visit, the patient’s admission packet was reviewed and contained a signed consent form which indicated Skilled Nursing services would be provided, and Physical Therapy to conduct an evaluation. At the time of this writing, no Physical Therapy services had been provided. During the record review on 10/15/24 at 10:00 a.m., section GG0170A1 documented – requires partial/moderate assistance to turn from side to side in bed, sit to lying, lying to sitting; Requires Substantial/Max assist to stand from sitting, Walk 10 feet, up and down 1 step… These findings were discussed with and acknowledged by the Admission Coordinator (AC #1) during an interview on 10/16/24 at 2:28 p.m. who responded, “She (patient) had PT in the past, but she refused the services then because the PT was young and good looking. She didn’t want her husband offended. AC #1 stated, “She didn’t want PT, but I didn’t document anything. That’s my fault.” The agency failed to ensure the patient’s Therapy needs were adequately met in the patient’s home.”

“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, it was determined the Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects in 1 (P-2) of 1 patient observed during a home visit, 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: P-2: The patient’s start of care was 10/15/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure and diabetes Mellitus. On 10/14/24 at 2:30 p.m., a scheduled survey home visit was conducted with the nurse (RN #1). During the visit, RN #1 reviewed the patient’s medications as this writer compared them to the medications on the plan of care. There were additional medications that were not included on the plan of care or medication profile such as, Vitamin B Complex, Liquid IV, and Nyamyc 100,000 units. These findings were reviewed with and acknowledged by the Admission Coordinator during an interview on 10/16/24 at 2:28 p.m. who reviewed the patient’s medications in the computer system and offered no response.”

“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 the required elements to address the individualized needs of the patient for 4 (P-1, P-3, P-5, P-6) patients, from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning and unmet care needs. Findings include: P-1: The patient’s start of care was 9/30/24 with diagnoses that included Essential Hypertension, Myalgia and Nausea and Vomiting. During the record review on 10/15/24 at 12:00 p.m., it was noted that the patient was ordered to received Skilled Nursing and Physical Therapy services. Upon review, the Plan of Care was noted to be void of interventions, parameters and associated goals to address the identified diagnoses. The interventions mentioned were vague in nature such as, assess cardiovascular status..., teach safety precautions..., instruct on energy conservation techniques... The Plan of Care did not address the individualized needs of the patient. These findings were reviewed with and acknowledged by the Admission Coordinator during an interview on 10/16/24 at 2:15 p.m. P-3: The patient’s start of care was 7/1/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the record review on 10/15/24 at 2:20 p.m., it was noted that the Plan of Care reflected that all 19 listed diagnoses exacerbated on 7/1/24 – date of admission to home care. There were no interventions, reportable parameters or associated measurable goals to address the exacerbated diagnoses. The interventions mentioned were vague such as, “Instruct on s/s respiratory distress…” No indication of what to look for; Assess/instruct for s/s DM complications…” No indication of what specifics to look for. The listed reflects parameters gave no instructions to notify Physician. The goals were not measurable such as, “will state understanding of measures to manage disease and identify s/s to report…, cardiac/respiratory status will return to stable… but did not indicate how this would be attained. The Plan of Care failed to address the individualized needs of the patient. These findings were reviewed with and acknowledged by the Admission Coordinator during an interview on 10/16/24 at 3:00 p.m. P-5: The patient’s start of care was 8/26/24, with diagnoses that included Hypertension, and chronic kidney disease. During record review on 10/15/24, it was noted that the patient was ordered to receive Skilled Nursing (SN) and Physical Therapy (PT) services. The Plan of Care (POC) failed to include interventions, and measurable goals to address the identified diagnoses. The Plan of Care did not address the individualized needs of the patient. P-6: The patient’s start of care was 8/19/24, with diagnoses that included Hypertension, atrial fibrillation, and dizziness. During record review on 10/16/24, it was noted that the patient was ordered to receive SN and PT services. The POC failed to include interventions, and measurable goals to address the identified diagnoses. The Plan of Care did not address the individualized needs of the patient. The findings were reviewed with and acknowledged by the Admission Coordinator (AC #1) during an interview on 10/17/24 at 11:15 a.m.”

“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 observation, interview and record review, the agency failed to ensure its skilled disciplines promptly notified the Physician for 1 (P-1) patient observed during a home visit who experienced vital signs below the set parameters, and 1 (P-2) patient observed with excessive expired medications, from a total of 7 sampled records reviewed, resulting in the potential for untreated health concerns and the potential for ingestion of harmful medications. Findings include: P-1: The patient’s start of care (SOC) was 9/30/24 with diagnoses that included Essential Hypertension and Myalgia. The plan of care (POC) reviewed on 10/14/24, ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. On 10/14/24 during a scheduled home survey visit with the Physical Therapy Assistant (PTA #1), the patient was noted to have a heart rate of 53. According to the POC, any heart rate reading below 56 was to be reported to the Physican. PTA #1 responded, “He’s always bradycardic.” (Low heart rate). PTA #1 failed to notify the Physician as instructed in the POC. Additionally, there was no documented evidence in the clinical record that the Physician had been notified. These findings were reviewed with the Admissions Coordinator (AC #1) during an interview on 10/16/24 at 2:15 p.m. who stated, “The disciplines have 60 days to document.” P-2: The patient’s SOC was 9/23/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure. The POC ordered SN and PT services to be provided. On 10/14/24 at 2:30 p.m., a scheduled survey home visit was conducted with the nurse (RN #1). During the visit, RN #1 reviewed the patient’s medications. During the review, RN #1 opened the patient’s refrigerator to search for a medication. Upon opening, a large plastic bin was observed that contained an excessive number of pill bottles and medications (over 30 medications). When queried, RN #1 reported, “Those are all her (patient) expired medications, but she refuses to throw them away. When asked if the Physician had been notified, RN #1 offered no response. These findings were reviewed with and acknowledged by AC #1 during an interview on 10/16/24 at 2:28 p.m. who responded, “I didn’t know about those medications when I did her start of care.””

“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, provided the patient’s current health status at the time of discharge, progress toward goals, and sent to the Physician within 5 days of the date of discharge for 2 (P-3, 4) of 2 patients discharged from the agency’s services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Policy: “Discharge Summary”, 2/2021 stated, “A Discharge Summary will be completed by the Skilled Nurse, Medical Social Worker, and/or Therapist..., will be sent within 5 days of patient discharge to the primary care practitioner...” P-3: The patient’s start of care was 7/1/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the record review on 10/15/24 at 2:20 p.m., it was noted that the patient was ordered to receive Skilled Nursing (SN) and Physical Therapy (PT) services. The patient discharged from PT services on 8/22/24. The PT Discharge Summary was dated 8/22/24. There was no documented evidence that the summary had been forwarded to the Physician. The patient discharged from SN and the agency’s services on 8/29/24. The SN Discharge Summary was void of a summary of care that detailed the course of care provided with responses, goals met versus unmet, and any potential continuing needs. Additionally, there was no documented evidence that the SN Discharge Summary had been sent to the Physician within 5 days of the date of discharge, as per this requirement. These findings were reviewed with and acknowledged by the Admissions Coordinator during an interview on 10/16/24 at 3:00 p.m. who reported, “I was told that we just had to inform the Physician of the Discharge Summary availability.” P-4: The patient’s start of care was 5/27/24, with diagnoses of spondylosis, osteoarthritis, and difficulty walking. During record review on 10/14/24, it was noted that the patient was ordered to receive Skilled Nursing (SN) and Physical Therapy (PT) services. The patient discharged from the agency on 7/19/24. There was no documented evidence of a discharge summary in the record. The Discharge OASIS E, under the Discharge Assessment section, documented the discharge summary/OASIS E, “Was available for the physician.” There was no documented evidence that a Discharge Summary was sent to the Physician within 5 days of the date of discharge. During an interview on 10/17/24 at 11:15 a.m., the Admission Coordinator (AC #1) acknowledged the above findings.”