Ahni Health Services Inc.

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of OASIS data to improve program effectiveness, quality of patient care and overall program improvement for all 30 current patients and all employees. A review of administrative records showed no OASIS data collection activities utilized in the agency’s QAPI Program for calendar year of 2023 and from January 01, 2024, to August 13, 2024. On 08/13/24 at 2:40 pm, Staff A stated they had no analysis of OASIS data available that showed improved quality of patient care for 2023 and from January 01, 2024, to August 13, 2024.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a performance improvement project through their QAPI Program for 30 patients and all employees. A review of QAPI records showed no review, data analysis, or status of performance improvement projects for the calendar year of 2023 and January 01, 2024, to August 13, 2024. On 08/13/24 at 2:40 pm., Staff A stated the agency had no documented performance improvement project review, data analysis of the effectiveness of the performance improvement project or status of the current performance improvement project for 2023 and from January 01, 2024, to August 13, 2024.”

“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 plan of care for two (Patients #5 and 6) of 7 patients. Patient #5 A review of the plan of care dated 05/14/24 to 07/12/24 showed a primary diagnosis of heart failure and showed no individualized plan of care development of all services necessary for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 04/24/24 to 06/22/24 showed a primary diagnosis of congestive heart failure and showed no individualized plan of care development of all services necessary for the management of the primary diagnosis. On 08/13/24 at 2:20 pm., Staff A stated the plan of care should have been fully developed for the primary diagnosis for Patients #5 and 6.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of a change in wound status for one (Patient #4) of seven patients. Patient #4 A review of the plan of care dated 05/22/24 to 07/20/24 showed a primary diagnosis of encounter for change or removal of nonsurgical wound dressing and documented a skilled nurse frequency of two visits per week for one week and two to three visits per week for eight weeks. Orders showed to provide wound care to the sacral area, every other day to cleanse wound with normal saline, apply skin prep to peri wound, apply plex foam dressing to wound bed, cover with dressing and secure with tape and to assess skin status and notify physician of significant changes. A review of the clinical record showed the following: A skilled nurse assessment dated 06/03/24 documented a wound to the sacral area with measurements of 1 centimeter long by 1 centimeter wide and 0.5 centimeters deep. A skilled nurse assessment dated 07/01/24 documented a wound to the sacral area with measurements of 1.5 centimeters long by 15 (charting error for 1.5) centimeters wide and 0.5 centimeters deep with no physician notification of a change in the wound status. A skilled nurse assessment dated 07/08/24 documented a wound to the sacral area with measurements of 2 centimeters long by 1.5 centimeters wide and 0.5 centimeters deep with no physician notification of a change, since 05/24/24, in the wound status. A skilled nurse assessment dated 07/15/24 documented a wound to the sacral area with measurements of 2 centimeters long by 1.5 centimeters wide and 0.5 centimeters deep with no physician notification of a change, since 05/24/24, in the wound status. On 08/13/24 at 2:15 pm., Staff A stated the physician should have been notified of change in the wound status for Patient #4.”