American Primary Healthcare 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 staff interview, the facility failed to ensure patients received home health services as written in the plan of care for two of three patients reviewed (Patient #10 and #40). This could affect all patients receiving services from the agency. The census was 39. Findings include: 1. Review of Patient #40’s medical record revealed a 09/17/23 start of care date. Review of the physician ordered plan of care for the certification period dated 09/17/23 to 11/15/23 revealed diagnoses including moderate intellectual disability, other disorders of the brain, congenital partial dislocation of hip, tracheostomy status, dysphagia, constipation, myopia, convulsions, glaucoma, and gastroesophageal reflux disease. The patient was homebound with a history of seizure, non-ambulatory and tracheostomy. He was developmentally delayed, required a Hoyer lift for transfer and needed a wheelchair for transportation. He made use of a nebulizer, oxygen concentrator, and enteral feeding tube. He received nothing by mouth and received enteral feeding every four hours. Functional limitations included ambulation, bowel and bladder incontinence, and speech. Orders were for skilled nursing visits Monday-Friday for up to 17 hours per day. Extra hours were also available and to be approved by the case manager as needed for care or respite. He was to receive tracheostomy care daily, nebulizers, bowel program, change complete pediatric mixed with Dual Cal and Pedialyte feeding tube every four hours. Enteral site care with dressing change as needed. Range of motion exercises, incontinence care, and pressure relief. The patient’s mother would prefer a nurse about 17 hours a day effective 09/17/23. His rehabilitation potential was good and there was no plan to discharge the patient due to requiring ongoing care. Review of the nurse time sheet revealed there were no services provided 09/22/23, 09/26/23, 09/27/23, and 09/28/23. A 09/25/23 Communication Note revealed the nurse had vacation planned from 09/22/23 till 09/28/23. The mother was notified by email but there was no evidence of the physician being notified of the missed visits. The nurse Staff E had a planned vacation from 10/20/23 till 11/04/23. Review of a 01/10/24 third party oversight agency email revealed on 11/04/23 the nurse called the patient and informed she would not be able to provide services until the end of January due to a family issue. The facility was not informed until 11/15/23 when Staff E reported she would not be returning to the case. There was no evidence of the patient’s mother or physician being notified of the nurse quitting the case. The facility did not have another nurse to provide the care. Review of a 12/01/23 Communication Note revealed Patient 40’s mom called the agency on 11/29/23 to report the nurse had not provided services since 10/19/23. Review of the undated facility policy titled, Missed Visits, revealed to be sure to notify the physician’s office and document who you spoke with, the date and time while completing the missed visit note. Select fax if you want the office to fax notification to the physician’s office and call the office to report this. Interview on 02/28/24 at 3:44 P.M. with Staff A verified the nurse had a planned vacation when hired. Since the vacation was so close to the start of care the facility did not have evidence of notifying the physician. Staff A verified the facility did not notify the patient’s mother that the nurse would not be returning at all when they were made aware on 11/15/23. The facility did not notify the physician of the missed visits or that the nurse was not returning to the case. Interview on 02/28/24 at 3:45 P.M. with Staff B revealed she did notify the physician but failed to document the notification. 2. Review of Patient #10’s medical record revealed a 02/06/24 start of care date with a current certification period from 02/06/24 to 04/05/24. Diagnoses included inherited spinal muscular atrophy, hypertension and scoliosis. The patient utilized a Hoyer lift and a wheelchair. Functional limitations included ambulation, contracture, dyspnea, and endurance. The patient was oriented. Home health aide services were to start 7:00 AM to 11:00 PM daily effective 02/06/24. Skilled nursing services were scheduled 11:00 P.M. to 7:00 A.M. but were 11:00 P.M. to 3:00 A.M. until they could staff. Review of time sheets revealed there were no aide services provided the 02/06/24 through 02/10/24. There was no evidence that the physician or the patient was made aware aide services were not starting as scheduled. Interview on 02/28/24 at 5:56 P.M. with Staff A verified the aide services were not started as planned. Staff A verified there was no evidence of the patient or physician being notified. Staff A indicated they had verbal conversations with the case manager and patient representative however, there was no documentation. This deficiency represents non-compliance investigated under Substantial Allegation 104032.”

“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, policy review, admission packet review, and interview, the facility failed to provide proper written notice in advance of reducing or terminating on-going care for one of three patients reviewed (Patient #40). This could affect all patients receiving services from the agency. The census was 39. Findings include: Review of Patient #40’s medical record revealed a 09/17/23 start of care date. Revie of the certification period dated 09/17/23 to 11/15/23 revealed diagnoses including moderate intellectual disability, other disorders of the brain, congenital partial dislocation of hip, tracheostomy status, dysphagia, constipation, myopia, convulsions, glaucoma, and gastroesophageal reflux disease. The patient was homebound with a history of seizure, non-ambulatory and tracheostomy. He was developmentally delayed, required a Hoyer lift for transfer and needed a wheelchair for transportation. He made use of a nebulizer, oxygen concentrator, and had a enteral feeding tube. He was nothing by mouth and received enteral feeding every four hours. Functional limitations included ambulation, bowel and bladder incontinence, and speech. Orders included skilled nursing visits Monday-Friday for up to 17 hours per day. Extra hours were also available and to be approved by the case manager as needed for care or respite. He was to receive tracheostomy care daily, nebulizers, bowel program, change complete pediatric mixed with Dual Cal and Pedialyte feeding tube every four hours. Enteral cite care with dressing change as needed. Range of motion exercises, incontinence care, and pressure relief. The patient’s mother would prefer a nurse about 17 hours a day effective 09/17/23. His rehabilitation potential was good and there was no plan to discharge the patient due to requiring ongoing care. Review of a 01/10/24 third party oversight agency email revealed on 11/04/23 the nurse called the patient and informed she would not be able to provide services until the end of January due to a family issue. The facility was not informed until 11/15/23 when Staff E reported she would not be returning to the case. On 11/15/23 a skilled discharge summary was written indicating the patient was being discharged due to unavailable personnel. It indicated the patient’s mom was aware and is to follow up with the case manager. Review of a 12/01/23 Communication Note revealed Patient #40’s Mom called the agency 1on 1/29/23 to report the nurse had not provided services since 10/19/23. There was no evidence of the patient’s mother or physician being notified of the nurse quitting the case on 11/15/23. Review of a 01/11/24 Inter-office Communication note revealed the case manager was notified of the agency’s inability to find a replacement nurse to staff Patient #40. It included to consider this their 30 day notice. There was no evidence of the patient/representative being provided the 30 day notice. Review of the home health agency admission packet, which was provided to patients on admission, the agency’s goal is to provide the patient with the services they need in a safe and effective manner in the patient’s place of residence; however, there may be times however where the agency is no longer able to do this. From here the agency must transfer the patient to another agency and discharge the patient from the agency. Examples sometimes when this might happen include but are not limited to the patient requested discharge transfer. There’s a change in the level of care the patient needs and your treatment goals are not met. The patient has repeatedly refused to comply with the treatment prescribed by the physician. The situation has developed that negatively affects the patient’s welfare or the safety of agency staff. Review of the policy titled, Discharge Criteria Planning, revised February 2021, revealed the patient is informed of the discharge plan in a timely manner and acknowledges understanding reason. The evaluation of the patient’s discharge needs and discharge planning must be documented in a timely manner. The evaluation must be included in the medical record and discussed with patient or representative. All relative information from the agency will be incorporated into the discharge plan to avoid delays. 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. Patients and families will be reminded to discard all old medicine list and to update health records with physician/ practitioners and retail pharmacies. Interview on 02/28/24 at 4:09 P.M. with Staff A revealed she was communicating with the patient’s mother by phone and informed the mother of the 30 day notice. Staff A verified there was no evidence in the patient’s record of the mother being notified. Staff A verified she did not provide a 30 day notice in writing. The last serviced day was 10/19/23. Staff A said she was advised by the case manager to give a 30 day notice, so she did via email. She verified the agency had already discharged the patient from the facility services on 11/15/23 without notice. Interview on 02/28/24 at 4:22 P.M. with Staff A revealed the patient’s mother was not notified of the nurse quitting the case until 11/29/23 when she called into the facility to inform them she had not had services since 10/19/23. The facility verified the documentation on the discharge paperwork indicating she was provided discharge instruction was inaccurate. Staff A acknowledged they did not follow their policy.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on record review and interview, the facility failed to show cause before discharging one of three patients reviewed (Patient #10). This could affect all patients receiving services from the agency. The census was 39. Findings include: Review of Patient #10’s medical record revealed a 02/06/24 start of care date with a current certification period from 02/06/24 to 04/05/24. Diagnoses included inherited spinal muscular atrophy, hypertension and scoliosis. The patient utilized a Hoyer lift and a wheelchair. Functional limitations included ambulation, contracture, dyspnea, and endurance. The patient was oriented. Review of a 02/27/24 communication note revealed a late note for 02/17/24 at 11:00 PM revealed the nurse arrived and checked the patient’s medication administration records. Noted red ink pen crossed out route of medication from oral to Gastrostomy tube as well as other changes different than the prescribed doctor’s orders. The patient’s grandmother made the changes on the medication administration record. The office was notified and the nurse was advised to keep evidence and continuing following the doctor’s orders. A late note entered 02/27/24 for 02/16/24 at 11:00 PM revealed the patient had not had a bowel movement for three days. The patient said the grandmother wouldn’t give her the Miralax or a fleet enema. A 02/28/24 communication note included a 30 day discharge notice was issued on 02/27/24. The case manager was notified 02/26/24. An email was sent 02/28/24 with a copy of the notice. The patient was advised of the notice on 02/27/24 and a copy mailed to her home. Review of the record revealed no actions or failed attempted resolutions to warrant a 30 day notice for cause. Interview on 02/28/24 at 5:56 P.M. with Staff A revealed the nurse was at the patient’s home daily. Staff A had no answer as to why the grandmother would be responsible to administer the fleets enema or medication when the nurse was there four to eight hours a day. She stated the record did not show a record of reasons or resolution attempts that would warrant a 30 day notice. She stated there were undocumented conversations with the case manager that would have shown more cause.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on interview, and record review, the agency failed to ensure each patient was provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care (G710). The cumulative effect of this systemic practice resulted in the agency’s inability to ensure that the patients’ skilled nursing needs would be met.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure a comprehensive assessment was completed within 48 hours of the patient’s return home from a hospital admission of 24 hours or more for reasons other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date for two of three patients reviewed (Patient #20 and #51). This could affect all patients receiving services from the agency. The census was 49. Findings include: 1. Review of Patient #20’s medical record revealed a start of care date of 06/20/23. Patient #20 had a diagnosis of mechanical breakdown of cardiac electrode, presence of implantable cardiac defibrillator, acute chronic systolic congestive heart failure, dyspnea, atrial fibrillation, ventricular tachycardia and transient ischemic attack. The patient was alert and oriented to person, place, time and situation. Review of the physician ordered plan of care for the certification period dated 10/18/23 to 12/16/23 revealed orders for skilled nursing one time a week. Record review revealed a Communication Note revealed Patient #20 was admitted to the hospital 09/22/23 and returned from the hospital 09/29/23. The Resumption of Care (ROC) comprehensive assessment was not completed until 10/04/23. Review of the facility’s Reassessments/Update of the Comprehensive Assessments Policy, revised 02/21, revealed each patient will have appropriate assessments performed and documented. Minimally, the comprehensive assessment ROC must be updated and revised within 48 hours of the patient’s return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests. Interview on 12/06/23 at 6:03 P.M. with Staff B verified the ROC was due by 10/01/23 and the nurse did not go to the home until 10/04/23, five days after the patient returned home to initiate the ROC and complete the assessment. 2. Review of Patient #51’s medical record revealed a 07/27/23 start of care date. The patient’s primary diagnosis was acute chronic congestive heart failure, with additional diagnoses of chronic kidney disease stage 3, morbid obesity due to excess calories, gout, hypo-osmolality and hyponatremia. Review of the physician ordered plan of care for the certification period dated 07/27/23 to 09/24/23 revealed orders for skilled nursing one time a week and two as needed visits. The nurse was to assess cardiovascular interventions with fluid detection, fluid restriction, self-monitoring of vital signs, assessing extremities, color, and temperature. Infusion therapy interventions included the change of the peripherally inserted central catheter (PICC) injection caps weekly to the PICC line after blood draws and as needed for leaking, obstruction, and the dressing change was to be every seven days and as needed. The patient was admitted to the hospital with exacerbated congestive heart failure on 08/05/23 and returned home 08/11/23. A visit was not made to see the patient until 08/14/23, three days after the patient was discharged home. On 08/14/23, the nurse completed a recertification comprehensive assessment instead of a ROC. Interview on 12/06/23 at 5:55 P.M. with Staff B verified the ROC was due by 08/13/23 and the nurse did not go to the home until 08/14/23, three days after the patient returned home, and verified the nurse completed a recertification comprehensive assessment instead of a ROC in error.”

“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 interview, and record review, the agency failed to ensure each patient was provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care for one of three patients reviewed (Patient #51). This could affect all patients receiving services from the agency. The census was 49. Findings include: Review of Patient #51’s medical record revealed a 07/27/23 start of care date with a primary diagnosis of acute chronic congestive heart failure, with additional diagnoses of chronic kidney disease stage 3, morbid obesity due to excess calories, gout, hypo-osmolality and hyponatremia. Review of the physician ordered plan of care for the certification period dated 07/27/23 to 9/24/23 revealed orders for a continuous Milrinone infusion (for heart failure) 0.2 micrograms per kilogram per minute, in 5% dextrose per pump via peripherally inserted central catheter (PICC line). The nurse was ordered to change injection caps weekly, after blood draws and as needed for leaking or obstruction. The dressing was to be changed every seven days and as needed. Clean with three alcohol, three betadine, air dry for three minutes, cover with occlusive dressing, gauze and tape. The patient was admitted to the hospital with exacerbation of congestive heart failure on 08/05/23 and returned home 08/11/23. On 08/14/23, three days after discharge, the nurse visited the patient and supplies were used consistent with changing the PICC line dressing. Review of Patient 51’s text messages revealed on 08/17/23 at 6:33 A.M. he texted his nurse, Staff W, that his PICC line dressing was coming off. He asked if she could come that day (Thursday) to change it. At 10:23 A.M. she responded saying she was not available and to call the office. His cell phone record revealed he called Staff W at 10:29 A.M. on 08/17/23, a 56 second call. At 1:39 P.M. she texted him the office daytime phone number. On 08/18/23 at 12:57 P.M. he responded that he just saw the text and asked what day she would be available. There was no evidence Patient #51 called the agency office on 08/17/23 the day the nurse texted him the phone number or on 08/18/23. On 08/19/23 at 10:32 A.M. he texted Staff W asking if she could come that day (Saturday). At 10:39 A.M. Staff W responded she was sorry; she was no longer seeing patients and to call the office number she gave him (daytime number). The phone record included a call to the daytime number at the office at 10:51 A.M. At 10:53 A.M. he responded by text that the office was closed. At 10:54 A.M. Staff W responded, “are you OK?” Patient #51 texted back at 10:54 A.M. “yes just need PICC bandage changed.” His phone records showed he called Staff W on 08/20/23 at 9:17 A.M., a 32 second call, and the office again on 08/20/23 (Sunday) at 9:18 A.M. His phone record revealed he phoned the office 08/21/23 (Monday) during normal office hours at 12:24 P.M., lasting one minute and 26 seconds, and again at 1:26 P.M., lasting 58 seconds. It was unknown whether he spoke to anyone at the office. Review of an Inter-office Communication Note dated 08/21/23 at 1:54 P.M. by Staff W revealed the patient texted the nurse on 08/18/23 and was given the office number because she was not available on 08/18/23 or over the weekend. The patient’s PICC line dressing was changed 08/14/23 and was due to be changed 08/21/23. There was no evidence a nurse visited the patient 08/21/23 to perform the dressing change. An Inter-office Communication Note by Registered Nurse Staff H dated 08/22/23 9:09 P.M. revealed she went to see the patient for the first time taking over as his case manager. He was in congestive heart failure. His weight went from 408 pounds to 446 pounds in a few days. His breathing was rapid and he was grunting with each breathe. Vital signs were 138/38 blood pressure, pulse 103-124 beats per minute. Oxygen saturation was 97%. Staff H advised the patient to call 911 for transportation to the hospital. Transportation would not take him to the hospital, so his wife took him. She called this evening and his wife said he was admitted to the hospital. An Inter-office Communication Note by Registered Nurse Staff H 08/31/23 2:22 A.M. revealed the patient passed away Saturday 08/27/23). There was no evidence of the physician being notified of the missed visit. Interview on 12/06/23 at 5:55 P.M. with Staff B revealed if Patient #51 left a message on the phone the Administrator would have received it and sent a message through group chat that he called. Staff B said she did not see a message or retrieve a phone message. Staff B verified if a patient was reaching out to his nurse for assistance and the nurse was unable to go to the home, she would expect the nurse to call the agency and let them know so arrangements could be made for someone else to make the visit. She would not expect the burden to be placed on the patient to make arrangements for other staff. She verified the physician was not notified of the missed visit and deviation from the plan of care when the PICC line dressing was not changed every seven days. Interview on 12/08/23 at 11:27 A.M. with Staff H revealed when she made the visit on 08/22/23 Patient #51 was in congestive heart failure and advised him to go to the emergency room. Interview on 12/12/23 at 2:41 P.M. with Staff W revealed the patient texted her and she was not available. She told him if it was urgent to go to the emergency room. She indicated she started to see less patients, there was a death in the family. When she was there on 08/14/23 she did the PICC line dressing change and flushed the catheter. He had heart failure. She did not see any new changes or anything out of the ordinary for him when she saw him 08/14/23. She thought she told the office she could not go. Looking at the record she did not notify the office she could not make a home visit when the patient was texting and calling her. She stated she should have given the patient the afterhours number. She has learned from this. She also thought she could only see him once a week and he did not have any as needed visits left.”