Able Health Care Services Inc. Chha

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on home visit observations, clinical records review and staff interview, the Agency failed to ensure patients are provided with the complaint procedure and complaint hot line number. This was evident in three (3) of three (3) home visits conducted (Patients #1, #2 and #3). Failure to inform patients of their rights to lodge complaints has the potential for negative patient outcomes. The findings are: 1) Patient #2 has a start of care date of 03/20/2013 with diagnoses of “Other Disorders of Psychological Development, Spastic Quadriplegia Cerebral Palsy, Sensorineural Hearing Loss Bilateral, Other Dystonia, Postural Kyphosis, Congenital Rubella Syndrome, Specific Developmental Disorder of Motor Function and Dependence on Wheelchair” as documented on the “Home Health Certification and Plan of Care” for certification period 11/17/2024 to 01/15/2025. The “Home Health Certification and Plan of Care” for certification period 11/17/2024 to 01/15/2025 documents an order “Skilled Nurse 1 wk1 (one visit a week for one week), Physical Therapy 4wk1, 3wk1, 4wk3, 1wk1, 4wk2. 3wk1 (four visits a week for one week, three visits a week for one week, four visits a week for three weeks, one visits a week for one week four visits a week for two weeks, three visits a week for one week), and Occupational Therapy 2wk9 (two visits a week for nine weeks)”. A Home Visit was conducted on 11/19/2024 with the Physical Therapist. Two patient admission packages were observed in the home. There was no evidence of a written patient complaint procedure and complaint hot line number. The patient’s caregiver reported she is unaware of the complaint number. An interview was conducted with the Director of Patient Services and Director of Nursing on 11/20/2024 at 11:19 AM, no explanantion was provided. The Agency did not ensure that the patient have available the home health agency complaint number and procedure. The survey findings were reviewed with the Director of Patient Services and Director of Nursing on 11/21/2024 at 03:55 PM. 2) Patient #3 has a start of care date of 04/08/2015 with diagnoses of Type 2 Diabetes Mellitus, Anoxic Brain Damage, Aphasia, Epilepsy, Retention of Urine, Hypothyroidism, Gastro-esophageal Reflux Disease, Long term use of Aspirin, Long term use of Hypoglycemis drugs, and Dependence on wheelchair as documented on the “Home Health Certification and Plan of Care” for certification period 10/17/2024 to 12/15/2025. The “Home Health Certification and Plan of Care” for certification period 10/17/2024 to 12/15/2025 documents an order “Skilled Nurse 1 wk1 (one visit a week for one week), Speech Therapy 1wk1,3wk8. Skilled Nurse to “evaluate and develop the plan of care”. A Home Visit was conducted on 11/19/2024 with the Speech Therapist. The patient admission packet was not available in the home. There was no evidence of a written patient complaint procedure and complaint hot line number. The patient’s caregiver reported she is unaware of the complaint number. An interview conducted on 11/20/2024 at 11:40 AM with the Director of Patient Services and Director of Nursing. No explanation was provided. The Agency did not ensure that the patient have available the home health agency complaint number and procedure. The survey findings were reviewed with the Director of Patient Services and Director of Nursing on 11/21/2024 at 03:55 PM. 3) Patient # 1 has a start of care date of 05/13/2015 with diagnoses of “Schizophrenia, Hypertension, Diabetes type 2, Disorder of Thyroid and long-term use of Insulin” as documented on the “Home Health Certification and Plan of Care” for certification period 09/22/2024 to 11/20/2024. The “Home Health Certification and Plan of Care” for certification period 09/22/2024 to 11/20/2024 documents orders for services “Skilled Nurse effective 1-week x1 weeks, 1 every 4-week times 4(one visit a week for one week, one visits every four weeks for four weeks). Skilled nurse to administration of Haldol 50mg per milliliter via intramuscular injection monthly. Insulin and Thyroid medication is monitored by Endocrinologist. Licensed professional to report vital signs falling outside the parameters(temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90)”. DME supplies: Glucometer, Medication includes Insulin Aspart 100 unit/milliliter-9units with lunch and 8 unit with dinner daily, and Tresiba FlexTouch 100-unit insulin pen of 15 units at bedtime hold for blood sugar less than 100mg/dl. A Home Visit was conducted on 11/19/2024 at 10 AM with the Register Nurse. Another agency patient admission package was observed in the home, patient stated “I throw it out” when ask about the agency admission packet, and the patient reported she is unaware of the complaint number. On review of clinical record it lacked documented evidence of a written patient complaint procedure with the department of health complaint hot line number. The survey findings and interview were conducted on 11/19/2024 at 3:00 PM with the Director of Patient Services and Director of Nursing. No explanation was provided.”

“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 observational home visits, record review and staff interview, the governing authority failed to ensure patient’s plan of care is comprehensive and individualized to meet patient’s medical, psychosocial, and functional limitations needs. This was evident for three (3) of eight (8) records reviewed (Patients #1, #3, and #5). Failure to ensure plan of care is individualized and comprehensive to meet patients needs has the potential for negative outcomes. The findings are: 1) Patient # 1 has a start of care date of 05/13/2015 with diagnoses of “Schizophrenia, Hypertension, Diabetes type 2,, Disorder of Thyroid and long term use of Insulin” as documented on the “Home Health Certification and Plan of Care” for certification period 09/22/2024 to 11/20/2024. The “Home Health Certification and Plan of Care” for certification period 09/22/2024 to 11/20/2024 documents orders for services “Skilled Nurse effective 1-week x1 weeks, 1 every 4-week times 4(one visit a week for one week, one visits every four weeks for four weeks). Skilled nurse to administration of Haldol 50mg per milliliter via intramuscular injection monthly. Insulin and Thyroid medication is monitored by Endocrinologist. Licensed professional to report vital signs falling outside the parameters(temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90)”. DME supplies: Glucometer, Medication includes Insulin Aspart 100 unit/milliliter-9units with lunch and 8 unit with dinner daily, and Tresiba FlexTouch 100-unit insulin pen of 15 units at bedtime hold for blood sugar less than 100mg/dl. The plan of care lacked documented evidence on who is monitoring finger stick and administering insulin injections. The Plan of Care lacked documented evidence to include the specific task of skilled nursing services of the Registered Nurse to include teaching/instruction of patient and caregiver in signs and symptoms of hyper/hypoglycemia, blood sugar parameters to report, instruct patient/caregiver in methods in insulin injection and prevention of skin breakdown, infection control, hand washing and safe disposal of sharps. The survey findings and interview were conducted on 11/19/2024 at 3:00 PM with the Director of Patient Services and Director of Nursing. No explanation was provided. 2) Patient # 5 has a start of care date of 06/20/2022 with diagnoses of “Congenital Malformation Syndrome, Chronic Respiratory failure with Hypoxia or Hypercapnia, Cerebral Palsy, Severe Intellectual disabilities, Contracture of right wrist and hand, Legal blindness, Gastrostomy status and Oxygen dependency” as documented on the “Home Health Certification and Plan of Care” for certification period 10/07/2024 to 12/05/2024. The “Home Health Certification and Plan of Care” for certification period 10/07/2024 to 12/05/2024 documents “Occupational therapy 3 times per week for eight weeks, one time a week for one week, therapy to focus on passive range of motion, . Licensed professional to report vital signs falling outside the parameters(temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90)”. DME supplies: catheter supplies, ceiling tract Hoyer lift, G-tube, Oxygen tank/concentrator, percussion vest and trach supplies”. The plan of care lacked documented evidence of who is responsible for assess and monitoring patient other health care needs, no indication of another agency providing nursing services for Foley catheter, trach, and G-tube. The survey findings and interview were conducted on 11/21/2024 at 3:00 PM with the Director of Patient Services and Director of Nursing. No explanation was provided. 3) Patient #3 has a start of care date of 04/08/2015 with diagnoses of Type 2 Diabetes Mellitus, Anoxic Brain Damage, Aphasia, Epilepsy, Retention of Urine, Hypothyroidism, Gastro-esophageal Reflux Disease, Long term use of Aspirin, Long term use of Hypoglycemic drugs, and Dependence on wheelchair as documented on the “Home Health Certification and Plan of Care” for certification period 10/17/2024 to 12/15/2024. The “Home Health Certification and Plan of Care” (Plan of Care) for certification period 08/18/202 to 10/16/2024 and 10/17/2024 to 12/15/2024 documents an order “Skilled Nurse 1 wk1 (one visit a week for one week), Speech Therapy 1wk1,3wk8. Skilled Nurse to “evaluate and develop the plan of care”. Skilled Nurse to assess/evaluate co-morbid conditions including TBI (Traumatic Brain Injury), Aphasia, and other conditions”. The “RN recertification with skills” (Comprehensive Assessment) visit note dated 10/15/2024, the Skilled Nurse documents the patient’s “Genito-urinary system assessment: Indwelling/Suprapubic Catheter”, and Durable Medical Equipment includes “Foley Catheter 16 French and drainage bag”. A Home Visit was conducted on 11/19/2024 with the Speech Therapist. The patient was observed to have an Indwelling Urinary Catheter attached to a Urine Drainage Bag. The Plan of Care lacks an order for the Indwelling/Suprapubic Catheter, Foley catheter size 16fr, balloon size, catheter care, frequency of catheter change and care giver education. The Agency did not establish an individualized Plan of Care that includes the indwelling catheter and treatments. An interview was conducted on 11/20/2024 at 11:40 AM with the Director of Patient Services and Director of Nursing. No explanation was provided. The survey findings were reviewed with the Director of Patient Services and Director of Nursing on 11/21/2024 at 03:55 PM.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and staff interview, the governing authority failed to ensure clinicians conform to physician orders, frequency and duration as specified in the patient’s plan of care. This was evident in the review of record for one (1) of eight (8) patient records (Patient #5). Failure to ensure patients receive care in accordance with physician orders have the potential for negative outcomes. The findings are: Patient # 5 has a start of care date of 06/20/2022 with diagnoses of Congenital Malformation Syndrome, Chronic Respiratory failure with Hypoxia or Hypercapnia, Cerebral Palsy, Severe Intellectual disabilities, Contracture of right wrist and hand, Legal blindness, Gastrostomy status and Oxygen dependency as documented on the “Home Health Certification and Plan of Care” for certification period 10/07/2024 to 12/05/2024. The “Home Health Certification and Plan of Care” for certification period 10/07/2024 to 12/05/2024 documents “Occupational therapy three times per week for eight weeks, one time a week for one week, therapy to focus on passive range of motion, Licensed professional to report vital signs falling outside the parameters (temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90)”. DME (Durable Medical Equipment) supplies: catheter supplies, ceiling tract Hoyer lift, G-tube, Oxygen tank/concentrator, percussion vest and trach supplies”. The clinical record lacks documented evidence of the Occupational Therapy visits conducted for 10/21/24, 10/25/24 and 111/09/24, no documentation of MD notification and replacement of service. Documented on the plan of care for certification period 10/07/2024 to 12/05/2024 “Licensed professional to report vital signs falling outside the parameters (temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90).” The Occupational Therapy “Recertification of Care” comprehensive assessment dated 10/04/2024 lacks documentation of the patient’s vital signs: Blood Pressure and Temperature readings. The Occupational Therapy “visit note reports” from 10/08/2024 to 11/18/2024 lacks documentation of the patient’s vital signs: Blood Pressure and Temperature readings. The therapist failed to follow the plan of care to assess all vital signs or indicate if they are within the parameters indicated in the plan of care. The survey findings and interview were conducted on 11/21/2024 at 3:00 PM with the Director of Patient Services and Director of Nursing. No explanation was provided.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on home visit observations, clinical record reviews and staff interviews, the Agency failed to ensure clinicians follow physician orders and patient records are accurate and contain all assessments and clinical interventions. This was evident in one (1) of three (3) observational home visits and records reviewed (Patient #5). Failure to ensure patients receive care as ordered and clinical records are comprehensive has the potential for negative patient outcomes. The findings are: Patient #2 has a start of care date of 03/20/2013 with diagnoses of “Other Disorders of Psychological Development, Spastic Quadriplegia Cerebral Palsy, Sensorineural Hearing Loss Bilateral, Other Dystonia, Postural Kyphosis, Congenital Rubella Syndrome, Specific Developmental Disorder of Motor Function and Dependence on Wheelchair” as documented on the “Home Health Certification and Plan of Care” for certification period 11/17/2024 to 01/15/2025. The “Home Health Certification and Plan of Care” for certification period 11/17/2024 to 01/15/2025 documents an order “Skilled Nurse 1 wk1 (one visit a week for one week), Physical Therapy 4wk1, 3wk1, 4wk3, 1wk1, 4wk2. 3wk1 (four visits a week for one week, three visits a week for one week, four visits a week for three weeks, one visits a week for one week four visits a week for two weeks, three visits a week for one week), and Occupational Therapy 2wk9 (two visits a week for nine weeks)”. The clinical record lacks documented evidence of a patient consent for services. A Home Visit was conducted on 11/19/2024 with the Physical Therapist. Two patient admission packages were observed in the home. There was no evidence of a written bill of rights, patient complaint procedure, and complaint hot line number. The patient’s caregiver reported she is unaware of the complaint number. The Agency was unable to provide evidence of patient consent for services, bill of rights, complaint procedure and complaint hot line. The survey findings and interview were conducted on 11/20/2024 at 11:19 AM with the Director of Patient Services and Director of Nursing, no explanation was provided. Patient # 5 has a start of care date of 06/20/2022 with diagnoses of “Congenital Malformation Syndrome, Chronic Respiratory failure with Hypoxia or Hypercapnia, Cerebral Palsy, Severe Intellectual disabilities, Contracture of right wrist and hand, Legal blindness, Gastrostomy status and Oxygen dependency” as documented on the “Home Health Certification and Plan of Care” for certification period 10/07/2024 to 12/05/2024. The “Home Health Certification and Plan of Care” for certification period 10/07/2024 to 12/05/2024 documents “Occupational therapy 3 times per week for eight weeks, one time a week for one week, therapy to focus on passive range of motion, Licensed professional to report vital signs falling outside the parameters(temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90)”. DME supplies: catheter supplies, ceiling tract Hoyer lift, G-tube, Oxygen tank/concentrator, percussion vest and trach supplies”. The clinical record lacks documentation of the Register Nurse comprehensive assessment of the start for evaluation of services on 06/20/2022. Documented on the plan of care for certification period 10/07/2024 to 12/05/2024 “Licensed professional to report vital signs falling outside the parameters(temp101, pulse 100, respirations 29 and blood pressure systolic 150, diastolic 90).” The Occupational Therapy “ Recertification of Care” comprehensive assessment dated 10/04/2024 lacks documentation of the patient’s vital signs: Blood Pressure and Temperature readings. The Occupational Therapy “visit note reports” from 10/ 08/11/2023 to 11/18/2024 lacks documentation of the patient’s vital signs: Blood Pressure and Temperature readings. The survey findings and interview were conducted on 11/21/2024 at 3:00 PM with the Director of Patient Services and Director of Nursing. No explanation was provided.”