Allfaith Homecare

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body provided oversight of the QAPI program for 94 current patients and all employees. Findings: A review of administrative records showed no governing body approval of the QAPI program or QAPI activities from 03/29/2023 - 11/11/24. On 12/04/24 at 12:15 pm, Staff A stated the governing body did not show approval of the QAPI program from 03/29/2023 - 11/11/24.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #4) of seven patients reviewed. Findings: Pt #4 A review of the clinical record showed a patient referral dated 10/31/24. Documentation showed an initial patient assessment and SOC dated 11/4/24 (four days later). Documentation showed no physician or patient request to delay the initial assessment. On 12/05/24 at 12:30 pm, Staff A stated the initial assessment for Pt #4 was not within 48 hours of the referral and she had no documentation as to why the admission was four days after the referral.”

“Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This Element is not met as evidenced by: Based on record review and interview, the agency failed to an OASIS was completed for one (Pt #1) of seven patients. Findings: Pt #1 A review of an OASIS recertification assessment dated 10/23/24 the form was incomplete and the following items were left blank: Episode Timing, VS, Past Medical History, Most Recent Immunizations, Health Screening, Advanced Directives, Functional Limitations, Sensory Status, Mental Status, Community Agencies/Social Service Screening, Safety Measures, Fire Assessment for Patients with Oxygen, Activities Permitted, Musculoskeletal, Fall Risk Assessment Tool, Self Care, Mobility, GU, Digestive, Pain Scale, Endocrine, Cardiovascular, Nutrition, Physician’s Orders of Diet Requirements, Pressure Ulcer/Injury Risk, Integumentary Status, Medication, Orders for Discipline and Treatments, Patient Strengths, Conclusions, Skilled Intervention, and Visit Assessment. On 12/05/24 at 12:22 pm, Staff A stated the document was not completed.”

“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 record review and interview, the agency failed to ensure an individualized POC to was developed for one (Pt #1) of seven patients. Findings: Pt #1 A review of a Plan of Care dated 10/27/24 to 12/25/24 showed an incomplete POC. The POC did not include the Primary Diagnosis, Secondary/Other Diagnosis, Advanced Directives, Mental Status, DME & Supplies, Services/Frequency, Prognosis, Safety Measures, Nutritional Requirements, Functional Limitations, Other, Activities, Rehabilitation Potential, Goals and Outcomes, Patient risk for ED and hospital re-admission, and Patient-Specific Interventions and education. On 12/04524 at 2:22 pm, Staff A stated the document was saved without being completed.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a POC for one (Pt #2) of seven patients. Findings: Pt #2 A review of the electronic medical record showed POC not started for the certification period 05/07/24 - 07/05/24. On 10/30/24 at 12:24 pm, Staff A stated the POC for Pt #2 had not been completed.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure preparation and availability of a clinical notes for three (Pt #1, 3 and %) of seven patients. Findings: Pt #1 A review of the electronic medical record showed a SN visit saved for the date of 10/28/24 but no SN note completed. Pt #3 A review of the electronic medical record showed a SN visit saved for the date of 11/26/24 but no SN note completed. Pt #5 A review of the electronic medical record showed SN visits for the dates of 10/17/24 and 10/31/24 the SN notes were not completed. On 12/05/24 at 12:22 pm, Staff A stated the visit notes for Pt #1, 3 and 5 SN visit notes were not completed within 48 hours of the visit.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an LPN supervisory visit for one (Pt #3) of seven patients. Findings: Pt #3 A review of POC dated 10/17/24 - 12/15/24 showed a SN visit frequency of every other week for nine weeks. A review of the clinical record showed LPN visits dated on 10/17/24, 10/30/24, 11/13/24, 11/26/24. Documentation showed no LPN supervisory visits completed 11/13/24 as scheduled in the electronic medical record for certification period 10/17/24 - 12/15/24 and no additional supervisory visits though 12/05/24. On 12/11/24 at 12:24 p.m., Staff A stated the LPN supervisory visit should have been completed but the nurse is behind on her documentation.”

“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 record review and interview, the agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Pt #3) of one patient with home health aide services. Findings: Patient #3 A review of a POC dated 10/17/24 - 12/15/24 showed a home health aide visit frequency of once a week for nine weeks. A review of the clinical record showed CHHA visits dated on 10/18/24, 10/25/24, 11/01/24, 11/08/24, 11/22/24, and 11/26/24. Documentation showed no supervisory visits completed from 10/17/24 - 12/05/24 (49 days without a supervisory visit). On 12/05/24 at 12:22 p.m., Staff A stated the CHHA supervisory visits should have been completed every 14 days.”