Hillside Certified Home Care Agency

“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 clinical record reviews, and staff interviews, the agency failed to ensure all paraprofessionals receive a complete HHA (Home Health Aide) plan of care when providing patient care. This was evident for one (1) of eight (8) clinical records reviewed (Patient: #5). Failure to ensure all paraprofessionals receive a complete HHA plan of care has potential for negative patient outcomes. The Findings Are: Patient #5 has a Start of Care (SOC) date of 09/24/2024 with the following diagnoses “Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye; Unspecified Visual Loss” documented in the Home Health Certification and Plan of Care for the Certification Period 09/04/2024 to 11/02/2024. The Home Health Certification and Plan of Care for the Certification Period 09/04/2024 to 11/02/2024 documents: “hha (home health aide) effective 09/08/2024 3WK2 (three times a week for two weeks).” The Aide Care Plan Report dated 11/03/2024 lacks documented evidence of the diet, durable medical equipment, and reporting of observations. The clinical record lacks documented evidence of a complete aide plan of care addressing the patient’s needs. On 11/07/2024 at 11:25am, the Administrator and the Director were interviewed and did not provide an explanation for the findings.”

“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 clinical records reviews and staff interview, the agency failed to ensure that all assessments document an accurate reflection of the patient status. This was evident for one (1) of eight (8) clinical records reviewed (Patient #6). Failure to ensure that all assessments document an accurate reflection of patient status, has the potential for negative patient outcomes. The Findings Are: Patient #6 has a Start of Care (SOC) date of 09/05/2024 with the following diagnoses “Pressure Ulcer of Left Heel, Stage 3; Encounter for Attention to Cystotomy”(a Suprapubic urinary catheter is inserted into the bladder through a surgical incision made above the pubic bone) documented in the Home Health Certification and Plan of Care for the Certification Period 09/05/2024 to 11/03/2024. The Visit Note Report dated 09/05/2024 documents: Genitourinary – Indicate genitourinary assessment: Incontinence. Urinary incontinence or Urinary catheter (Indwelling urinary catheter is inserted into the bladder through the urethra and remains in the bladder) presence: patient is incontinent. The Client Coordination Note Report dated 09/18/2024 (for visit 09/17/2024), 10/04/2024 (for visit 10/02/2024), and 10/12/2024 (for visit 10/09/2024) documents: Foley catheter (type of indwelling catheter) drains adequate amount of clear yellow urine. The comprehensive assessment lacks documented evidence of the suprapubic catheter. (Patient #6 has a suprapubic catheter, not a foley catheter). The Home Health Certification and Plan of Care for the Certification Period 09/05/2024 to 11/03/2024 documents: Skilled Nurse to perform/teach pressure ulcer care to Left Heel stg (stage) 3 PU (pressure ulcer) cleanse with NS (normal saline) apply Xeroform cover with Kling bandage. The Wound Record Report dated 09/10/2024, 09/17/2024, 09/24,2024, 09/26/2024, 10/02/2024, 10/04/2024, 10/09/2024, and 10/14/2024 lacks documented evidence of wound measurement and description for the Left Mid Distal Plantar, pressure ulcer Stage III. There is no documented evidence of a complete and accurate assessment of the patient’s status in the comprehensive assessment including wound measurements and documentation of the correct catheter. On 11/07/2024 at 11:25am, the Administrator and the Director were interviewed and did not provide an explanation for the findings.”

“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 clinical records review and staff interview the agency failed to ensure each individualized plan of care includes all the required information. This was evident for two (2) of eight (8) clinical records reviewed (Patient #1, and #6). Failure to ensure each individualized plan of care includes all the required information, has the potential for negative patient outcomes. The Findings Are: 2. Patient #6 has a Start of Care (SOC) date of 09/05/2024 with the following diagnoses “Pressure Ulcer of Left Heel, Stage 3; Encounter for Attention to Cystotomy” documented in the Home Health Certification and Plan of Care for the certification period 09/05/2024 to 11/03/2024. The Home Health Certification and Plan of Care for the certification period 09/05/2024 to 11/03/2024 documents: “Skilled Nurse to instruct patient / caregiver in indwelling urinary catheter management.” “Skilled Nurse to perform/teach pressure ulcer care to Left Heel stg (stage) 3 PU (pressure ulcer) cleanse with NS (normal saline) apply Xeroform cover with Kling bandage.” The Visit Note Report dated 09/05/2024 documents: Left Plantar Foot: Mid Dist (distal) Plantar, LT (left), PU (pressure ulcer) Stage III. The Patient Information Report dated 08/28/2024 documents: The suprapubic catheter was changed on 8/12/24. Pt. (patient) will f/u (follow up) with urology on monthly basis for cath (catheter) change. The plan of care lacks documented evidence of the correct site of the wound and suprapubic catheter. There is no documented evidence of a complete and accurate plan of care. On 11/07/2024 at 11:25am, the Administrator and the Director were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 10/13/2024 with the diagnoses Encounter for Other Orthopedic Aftercare, End Stage Renal Disease documented in the Home Health Certification and Plan of Care for Certification Period 10/13/2024 to 12/11/2024. The Registered Nurse/Skilled Nurse Visit Note Report dated 10/13/2024 documents: the “Pt (Patient) has dialysis (arteriovenous) fistula at LUE (left upper extremity)” and receives dialysis three times a week. The Visit Note Repot(s) document that the skilled professionals performed blood pressure readings on the patient’s left arm on the following dates: 10/13/2024 (Skilled Nurse), 10/15/2024 (Physical Therapist), 10/23/2024 (Skilled Nurse), 10/23/2024 (Occupational Therapist), and 10/28/2024 (Occupational Therapist). The Home Health Certification and Plan of Care for Certification Period 10/13/2024 to 12/11/2024 lacks documented evidence of a safety measure to prevent blood pressure readings on the patient’s left arm/dialysis vascular access site. There is not documented evidence that the individualized plan of care includes safety measures to prevent injury and risk of complications of the patient’s vascular access site used for dialysis. On 11/06/2024 at 11:25am, the Administrator and the Director were interviewed and did not provide an explanation for the findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on clinical records reviews and staff interview, the agency failed to ensure the clinician communicated with all physicians involved in the patient’s care. This was evident for one (1) of eight (8) clinical records reviewed (Patient #6). Failure to communicate with all physicians involved in the plan of care has the potential for negative patient outcomes. The Findings Are: Patient #6 has a Start of Care (SOC) date of 09/05/2024 with the following diagnoses “Pressure Ulcer of Left Heel, Stage 3; Encounter for Attention to Cystotomy” documented in the Home Health Certification and Plan of Care for the Certification Period 09/05/2024 to 11/03/2024. The Client Coordination Note Report dated 09/05/2024 documents: “will f/u (follow up) with DPM (Doctor of Podiatric Medicine) 9/6 for further instructions”. The Client Coordination Note Report dated 09/23/2024 documents: “As per SN (skilled nurse), multiple attempts were made to f/u (follow up) regarding discussing WOCN (Wound, Ostomy, and Continence Nurse) recommendation with MD (medical doctor) on file, no response.” The clinical record lacks documented evidence of the coordination with the Podiatrist from 09/06/2024 to 09/22/2024. On 11/07/2024 at 11:25am, the Administrator and the Director were interviewed and did not provide an explanation for the findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure that all Home Health Aides receive onsite supervision every 14 days. This was evident for one (1) of eight (8) clinical records reviewed (Patient #5). Failure to ensure that all Home Health Aides receive onsite supervision every 14 days, has the potential for negative patient outcomes. The Findings Are: Patient #5 has a Start of Care (SOC) date of 09/24/2024 with the following diagnoses “Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye; Unspecified Visual Loss” documented in the Home Health Certification and Plan of Care for the certification period 09/04/2024 to 11/02/2024. The Home Health Certification and Plan of Care for the Certification Period 09/04/2024 to 11/02/2024 documents: hha (home health aide) effective 09/08/2024 3WK2 (three times a week for two weeks). The Duty Sheets documents aide services being provided on 9/11/2024, 09/13/2024, 09/16/2024, 09/18/2024, 09/20/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/07/2024, 10/09/2024, 10/11/2024, 10/14/2024, 10/16/2024, 10/18/2024, 10/23/2024, and 10/25/2024. The clinical record documents aide supervision on 09/30/2024, 10/14/2024, and 11/01/2024. The clinical record lacks documented evidence of aide supervision every 14 days. On 11/07/2024 at 11:25am, the Administrator and the Director were interviewed and did not provide an explanation for the findings.”