Home Sweet Home Ace Care LLC

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review, review of communication logs, review of scheduled visits, and staff interview, the agency failed to ensure OASIS assessments were completed upon a patient’s transfer to a hospital. This affected three (Patient #1, Patient #2, and Patient #3) out of three patients reviewed. The agency census was 24. 1) Review of the electronic medical record for Patient #1 and a calendar of scheduled visits revealed Patient #1 was in the hospital from 10/19/23 through 11/01/23. No transfer OASIS was found after Patient #1 was admitted to the hospital. Interview on 05/28/24 at 12:58 PM the Administrator confirmed there were no transfer OASIS completed after Patient #1 was admitted to the hospital. 2) Review of an agency Patient Communication Log revealed on 01/20/24 the aide was informed by Patient #2 they were in the hospital for chest pain. Review of the medical record for Patient #2 did not reveal a transfer OASIS to the hospital. 3) Review of the agency schedule calendar revealed Patient #3 was admitted to the hospital on 03/18/24 to 03/22/24. Review of the medical record for Patient #3 did not reveal a transfer OASIS to the hospital. Interview on 05/29/24 at 4:10 PM the administrator confirmed there was no transfer OASIS completed when Patient #2 and Patient #3 were admitted to the hospital. 1. 2.”

“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 staff interview, the agency failed to develop a plan of care for the necessary services for one (Patient #1) of three patients reviewed for plan of care. The census was 24. Review of the medical record for Patient #1 revealed a start of care date of 08/23/24. Diagnosis included malignant neoplasm of the breast. There was no care plan developed Review of a Waiver Service Plan, effective 06/23/23 through 05/31/24, revealed the HHA was to provide assistance with bathing, dressing, feeding, toileting, and assist with ambulation and transfers. Also assist with homemaking, meal prep, shopping, and medication reminder, for 24 hours per week, from 11/15/23 through 02/25/24. Interview on 05/28/24 at 12:00 PM the Administrator stated they “dropped the ball” and confirmed there was no plan of care for the services provided to the patient.”

“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 policy review, record review, and staff interview, the agency failed to ensure the home health aide (HHA) had a plan of care written by the registered nurse (RN) to follow when providing services. This affected two (Patient #1 and #3) out of two patients reviewed with HHA visits. The census was 24. i Review of the medical record for Patient #1 did not reveal a care plan written by the RN for the HHA to follow. The medical record and time sheets for the HHA revealed visits on 09/06/23, 09/07/23, 09/10/23, 09/11/23, 09/17/23, 09/18/23 and 09/24/23 were made. Review of the medical record for Patient #3 did not reveal a care plan written by the RN for the HHA to follow. The medical record for Patient #3 and time sheets for the HHA revealed visits were made from 04/28/24 through 05/18/24. Review of the undated agency policy titled “Care Planning Process” revealed the patient care plan for the HHA will be developed by a RN (or a therapist or Speech Language Pathologist, if nursing not ordered) prior to Home Health Aide rendering care. This will be reviewed at least every 14 days during supervisory visit and based on patient’s health status and environment. Interview on 05/29/24 at 2:58 PM the Administrator confirmed there were no plan of cares written by the RN for the HHA to follow for Patient #1 and Patient #3.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, review of agency policy, and staff interview, the agency failed to ensure the patient was provided written notification of being discharged from services. This affected one (Patient #1) out of two discharged patients reviewed. The census was 24. Review of the medical record for Patient #1 revealed a start of care date of 06/23/24. Diagnosis included malignant neoplasm of the breast. Review of a Waiver Service Plan, effective 06/23/23 through 05/31/24, revealed personal care services 24 hours a week and nursing assessments every 60 days were ending on 02/25/24 due to change in service provider, increase in service, and termination of service. On 02/26/24 Patient #1 received services from a new provider. The record contained no written evidence Patient #1 was notified of being discharged from this agency. Review of the undated agency policy titled “Discharge Criteria,” revealed the patient is informed of discharge plan in a timely manner and acknowledges understanding of the reason. Interview on 05/28/24 at 1:28 PM, the Administrator confirmed there was no evidence Patient #1 had been notified of the impending discharge.”

“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, policy review, and staff interview, the agency failed to ensure a medication profile was completed for each patient. This affected three (Patient #1, #2 and #3) out of three patients reviewed. The census was 24. 1) Review of the medical record for Patient #1 did not reveal a medication profile had been completed since the start of care dated 08/23/23. 2) Review of the medical record for Patient #2 did not reveal a medication profile had been completed since the start of care dated 10/13/23. 3) Review of the medical record for Patient #3 did not reveal a medication profile had been completed since the start of care dated 11/06/2019. Review of the undated agency policy titled “Initial assessment/Comprehensive Assessment” revealed each patient admitted will receive a comprehensive assessment. Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, etc.) to identify side effects, drug interactions, noncompliance with medications, duplicate therapy, ineffective therapy, potential adverse effects, medication reactions, significant medication issues, omissions, dosage errors and management of oral and injectable medications. Interview on 05/29/24 at 3:26 PM the Director of Nursing confirmed a medication profile had not been completed since admission for Patient #1, Patient #2, and Patient #3.”

“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, policy review, and staff interview, the agency failed to ensure there were physician orders for the services provided. This affected three (Patient #1, #2 and #3) out of three patients reviewed. The census was 24. 1) Review of the medical record for Patient #1 revealed start of care 08/23/23. There were no physician orders for services to be provided. The record and the staff time sheets revealed the home health aide (HHA) had completed visits on 09/06/23, 09/07/23, 09/10/23, 09/11/23, 09/17/23, 09/18/23 and 09/24/23. The HHA assisted with personal care, activities of daily living and light housekeeping. Review of the undated agency policy titled “Physician’s Orders – Verbal Orders” revealed drugs and treatments are administered by the agency staff only as ordered by the physician. Orders for patient care are obtained from the physician. Interview on 05/28/24 at 12:00 PM, the Administrator confirmed there were no physician physician orders for services provided to Patient #1 since start of care on 08/23/23. 2) Review of the medical record for Patient #2 revealed start of care on 10/13/23. Patient #2 used oxygen at 4 Liters per minute as needed. The skilled nurse was to go every 60 days to assess and evaluate Patient #2. A recertification comprehensive assessment was completed 01/08/24. The skilled nurse was to go every two months to assess and evaluate. There were no physician orders for the skilled nurse to visit every two months. Interview on 05/29/24 at 3:00 PM the Administrator confirmed there were no signed physician’s orders for the two skilled nurse visits that were made. 3) Review of the medical record for Patient #3 revealed start of care 11/06/2019. There were no physician’s orders. The medical record and time sheets found for the HHA revealed visits were made from 04/28/24 through 05/18/24. The HHA assisted with personal care, activities of daily living and light housekeeping. Interview on 05/29/24 at 4:30 PM the Administrator confirmed there were no physician orders found for services provided to Patient #3 since start of care on 11/06/2019.”

“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 policy review, review of communication logs, record review, and staff interview, the agency failed to ensure a discharge summary was completed and sent to the physician at discharge. This affected two (Patient #1, Patient #2) out of three patients reviewed admitted to the hospital. The census was 24. f 1) Review of the medical record for Patient #1 revealed a start of care date of 08/23/24. Diagnosis included malignant neoplasm of the breast. Review of a Waiver Service Plan, dated 06/23/23 through 05/31/24, revealed personal care services 24 hours a week and nursing assessments every 60 days were ending on 02/25/24 due to change in service provider, increase in service, and termination of service. On 02/26/24 Patient #1 received services from a new provider. There was no evidence a discharge summary was completed and sent to the health care provider. Interview on 05/28/24 at 1:38PM the Director of Nursing (DON) confirmed there was no discharge summary completed and sent to the physician. 2) Review of an agency Patient Communication Log revealed on 02/19/24 Patient #2 was hospitalized, and the agency had not heard from the patient since that time, so Patient #2 was discharged. Further review revealed on 02/29/24 Patient #2 expired in the hospital. Review of the medical record for Patient #2 did not reveal a discharge summary. Interview on 05/29/24 at 4:10 PM the Administrator confirmed there was no discharge summary completed and sent to the physician. Review of the undated agency policy titled “Discharge Criteria,” revealed the patient is informed of discharge plan in a timely manner and acknowledges understanding reason. The Physician and other care providers will be informed and knowledgeable of discharge. Patients will receive verbal or written discharge Instructions. A complete list of reconciled medications will be provided to each patient on discharge. The list will be explained to patient/family and interaction documented.”