Pelacho Home Health, Inc.

“Exercise of rights CFR(s): 484.50(b)(1)(2)(3) Standard: Exercise of rights. (1) If a patient has been adjudged to lack legal capacity to make health care decisions as established by state law by a court of proper jurisdiction, the rights of the patient may be exercised by the person appointed by the state court to act on the patient’s behalf. (2) If a state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state law, the patient’s representative may exercise the patient’s rights. (3) If a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the patient may exercise his or her rights to the extent allowed by court order. This Standard is not met as evidenced by: Based on review of agency policy, record review and interview, the Home Health Agency (HHA) failed to ensure Advanced Directives were entered into the Electronic Medical Record (EMR) for two of 13 patients (Patient (P ) P2 and P9) reviewed in the sample. The HHA further failed to ensure Medical Durable Power of Attorney (MDPOA) were placed in the patient’s record. This failure had the potential to affect all 101 patients receiving services from the HHA who may have had designated Advance Directives in place. Findings include: Review of the Agency’s undated “Agency Policy on Advance Directives” revealed “Our agency complies with the Patient Self-Determination Act of 1990 which requires us to: …Document advance directives prominently in your medical record and inform all staff (of your Advance Directives)”. 1.Review of P2’s Home Health Certification and Plan of Care revealed P2 had diagnoses including history of stroke and right hip fracture. Review of P2’s Plan of Treatment, dated 12/28/24, revealed P2 had an Advance Directive (Medical Durable Power of Attorney (MDPOA) in place. The record indicated the resident’s wife was the designated MDPOA and indicated copies of the MDPOA were to be obtained by the agency and placed in the patient’s record. Further review of P2’s record revealed nothing to indicate the MDPOA had ever been obtained and placed in the patient’s record. 2.Review of P9’s Home Health Certification and Plan of Care revealed P9 had diagnoses including chronic kidney disease requiring dialysis. Review of P9’s Plan of Treatment, dated 09/30/24 revealed P9 had an Advance Directive/MDPOA in place. The record indicated the resident’s wife was his designated MDPOA and indicated copies of the MDPOA were to be obtained by the agency and placed in the patient’s record. Further review of P9’s record revealed nothing to indicate the MDPOA had ever been obtained and placed in the patient’s record. During an interview on 03/07/25 at 11:00 AM, the Director of Nursing (DON) confirmed P2 and P9’s MDPOA paperwork had never been obtained or placed in the patient’s records and stated the Advance Directive documents were expected to be placed in the patient’s record timely after the agency became aware the residents had Advance Directives in place.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure comprehensive discharge information/instructions were provided for one of 13 patients (Patient (P ) P12) reviewed in the sample. This failure had the potential to affect all 101 patients receiving services from the HHA at the time of their discharge from the agency. Findings include: Review of P12’s Home Health Certification and Plan of Care revealed P12 had diagnoses including bladder cancer, type 2 diabetes, and presence of indwelling suprapubic urinary catheter device. Review of P12’s Plan of Treatment, dated 11/19/24 revealed P12 was receiving ordered nursing services from the agency including weekly maintenance and assessment of the patient’s urinary catheter, monthly replacement of the patient’s urinary catheter, and teaching and assessment related to the patient’s type 2 diabetes and blood sugar management. Further review of P12’s record revealed the patient was discharged from the agency on 01/13/25. Review of the patient’s Discharge Summary dated 01/13/25 revealed P12’s care was being transferred to another unnamed agency and indicated the patient’s discharge disposition was supported by family. The document indicated discharge instructions provided to P12 at the time of discharge included, instructed to report to PCP (Primary Care Physician) for any significant changes in patient’s condition. There were no additional discharge instructions indicated, including instructions related to care of the patient’s urinary catheter, management of diabetes and blood sugars, review of the patient’s medication regimen, instructions related to any potential upcoming medical appointments, or contact information for medical providers, medical supply providers, or agency or emergency personnel. During an interview on 03/07/25 at 11:00 AM, the Director of Nursing (DON) confirmed P12’s discharge summary/instructions did not contain adequate information to ensure the patient’s safe discharge from the agency.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure that at least one Performance Improvement Project (PIP) was in place and ongoing via the agency’s Quality Assessment and Performance Improvement (QAPI) program. This deficient practice had the potential to affect all 101 patients receiving services from the HHA when ongoing agency wide performance issues were potentially not identified. Findings include: Review of the agency’s “Quality Assessment and Performance Improvement (QAPI) Plan and Program Policy” dated 03/2018 revealed, “Agency must take actions aimed at performance improvement and, after implementing these actions, must measure its success and track performance to ensure that improvements are sustained:” and “QAPI activities include ongoing monitoring of at least: One important administrative aspect of administrative/operational function of the Agency.” Review of the Agency’s QAPI documentation revealed ongoing analysis of patient data was occurring and this analysis was routinely reviewed by the QAPI committee, however review of the documentation revealed all designated targets were being met each quarter and no ongoing PIPs were necessary and so none had been initiated. During an interview on 03/07/25 at 11:00 AM, the Medical Records Manager (MRM) indicated was responsible for collecting and analyzing patient and agency data and confirmed, based on a quarterly analysis of the collected data, all targets were being met and no PIPs had been initiated by the QAPI team. The Director of Nursing (DON) confirmed this information and stated was unaware of the Federal requirement for at least one ongoing PIP to be conducted by the QAPI team.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure medication orders were accurately documented in the record for three of five sampled patients (Patient (P) 1, P2 and P4) whose medications were observed in their home. This deficient practice had the potential to affect all 101 patients receiving services from the HHA who have any changes in physician orders. Findings include: Review of the agency’s “Medication Orders Policy” dated 03/2018 revealed, “The agency will minimize errors and misinterpretation of written or verbal medication orders;” and “The medication profile will be accurate.” Review of the agency’s “Medication Reconciliation Policy” dated 03/2018 revealed, “At the time of admission, the admitting RN (Registered Nurse), PT (Physical Therapist), or SLP (Speech and Language Pathologist) will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency;” and “Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.” 1.An observation during P1’s homecare visit performed by RN2 on 03/05/25 at 9:40 AM, revealed medications on the patient’s group home Medication Administration Record (MAR) did not match the medication list entered into the agency’s Electronic Medical Record (EMR). Review of P1’s medical record revealed orders, entered in the EMR, for P1 to receive Acetaminophen 500 milligrams (MG) as needed for pain (no frequency orders were entered for the medication), Tramadol 50 MG as needed for pain (no frequency orders were entered for the medication), calcium carbonate 500 MG daily as a supplement, and Lorazepam 0.5 MG as needed for anxiety (no frequency orders were entered for the medication). In addition, the patient’s Agency record did not indicate any orders for routine Acetaminophen 1000 MG to be administered routinely at 7:00 AM and 2:00 PM, for Amlodipine 5 MG to be administered once daily at 7:00 AM, for Lorazepam 1 MG to be administered routinely at 7:00 AM and 5:00 PM, for Potassium Chloride Extended Release 10 milliequivalents as a supplement routinely at 7:00 AM, for Senna Plus 86.-50 MG to soften stools routinely twice daily at 7:00 AM and 5:00 PM, for Thera M (a multivitamin) one tablet daily routinely at 7:00 AM, for Trazadone 50 MG every night at bedtime routinely for sleep, and Vitamin D2 5000 units routinely at 7:00 AM for supplement. Review of P1’s home MAR revealed the patient was receiving Acetaminophen 1000 MG routinely at 7:00 AM and 2:00 PM and every eight hours as needed, Amlodipine 5 MG routinely once daily at 7:00 AM, Lorazepam 1 MG routinely at 7:00 AM and 5:00 PM, Tramadol 50 MG every eight hours as needed for pain, Potassium Chloride Extended Release 10 milliequivalents routinely at 7:00 AM, Senna Plus 86.-50 MG twice daily at 7:00 AM and 5:00 PM, Thera M one tablet daily at 7:00 AM, Trazadone 50 MG every night at bedtime, and Vitamin D2 5000 units daily at 7:00 AM. 2. An observation during P2’s homecare visit performed by Home Health Aide (HHA2) on 03/04/25 at 1:50 PM, revealed medications on the patient’s home medication list did not match the medication list entered into the agency’s EMR. Review of P2’s medical record revealed orders, entered in the EMR, for P2 to receive COQ-10 (a supplement) 400 MGs daily, Midodrine 2.5 MG twice daily for hypertension, Oxybutynin 10 MG daily for urinary frequency, Miralax 17 grams twice daily for a laxative/stool softener, Senna one tablet daily routinely as a laxative, and Memantine 5 MG twice daily for memory loss. Review of P2’s home medication list and home medications revealed the patient was receiving Memantine 10 MG twice daily for memory loss and Senna one tablet daily as needed as a laxative. The record and home medication review revealed P2 was not receiving the COQ-10, Midodrine, Oxybutynin, or Miralax as indicated by the agency’s EMR. 3. An observation during P4’s homecare visit performed by Licensed Vocational Nurse (LVN1) on 03/04/25 at 4:25 PM, revealed medications on the patient’s home medication list did not match the medication list entered into the agency’s EMR. Review of P4’s medical record revealed orders, entered in the EMR, for P4 to receive Dabigantron (a blood thinning medication) 150 MG twice daily, Senna 8.6 MG twice daily as a stool softener, Loratadine (an antihistamine medication) 10 MG daily, Metoprolol Succinate (a blood pressure reducing medication) 25 MG twice daily, and pantoprazole (an acid reducing medication) 40 MG daily. Review of P4’s home medication list and home medications revealed the patient was receiving Dabigantron 150 MG once daily, Metoprolol Succinate 50 MG once daily and 100 MG once daily, and Omeprazole 40 MG once daily and revealed the patient was not receiving Senna, or Loratadine as indicated in the agency’s EMR. During an interview on 03/07/25 at 11:00 AM, the Director of Nursing (DON) confirmed medication orders in the agency’s EMR were expected to match the medication being administered to each patient in their home.”

“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 interviews, the Home Health Agency (HHA) failed to ensure physician’s orders were routinely followed for one of 13 patients (Patient (P ) P12) reviewed in the sample. This failure had the potential to affect all 101 patients who relied on accurate implementation of physician’s orders to ensure safe and quality care. Findings include: Review of P12’s Home Health Certification and Plan of Care revealed P12 had diagnoses including bladder cancer and presence of indwelling suprapubic urinary catheter device. Review of P12’s Plan of Treatment, dated 11/19/24, revealed physician’s orders for agency nursing staff to change P12’s indwelling suprapubic catheter monthly. Review of P12’s weekly Skilled Nursing Visit Notes, dated 11/22/24, 11/29/24, 12/06/24, 12/13/24, 12/20/24, 12/27/24, 01/03/25, and 01/10/25 revealed the same narrative note that indicated, “Using aseptic technique: SN (Skilled Nurse) changed suprapubic catheter with 20 Fr/10 ML (20 French/10 milliliter) (catheter). Flushed with 60 ml (milliliter) nss (normal saline solution), and replace (catheter) leg bag.” The notes indicated the skilled nurse changed P12’s suprapubic urinary catheter weekly rather than monthly as ordered by the physician. During an interview on 03/07/25 at 11:00 AM, the Director of Nursing (DON) confirmed the documentation in P12’s nursing notes indicated the patient’s urinary catheter had been changed weekly rather than monthly as ordered. The DON stated expectation was physician’s orders would be followed related to all patient care.”