First Hope Home Care Agency Inc.

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on a review of clinical records, the home health agency’s (HHA) emergency preparedness documents, and an interview with the administrator, the HHA failed to provide evidence that the emergency preparedness policies and procedures were reviewed at least every two (2) years, and that an individualized emergency preparedness plan was established for two (2) of two (2) CR’s reviewed: CR#1 and CR#2. Findings include: A review of the HHA’s Emergency Preparedness Plan and Program (EPPP) found that it was dated 10/15/2018. There was no evidence that the EPPP was reviewed every two (2) years. The HHA’s Policy Initial Assessment/Patient Admission reviewed on October 4, 2024 at 12:00 PM states in part, “On the admit visit, the consent Bill of Rights, Advance Directives and Emergency Preparedness will be discussed prior to care being rendered.” The HHA’s Patient Information Package reviewed on October 4, 2024 at 9:40 AM contains a blank document titled Triage Determination which is intended to assign one (1) of three (3) criticality classifications to a patient in the event of a disaster. Class I notes that “services required today.” Class II notes that “services can be postponed for 24 to 48 hours without adverse effects on the patient.” Class III notes that “services can be postponed for 72 to 96 hours without adverse effects on the patient.” The bottom of the document states, “Please return this form to the office for the original clinical record.” A review of CR’s was conducted on October 4, 2024 starting at 9:10 AM. The Start of Care (SOC) and Certification Period (CP) is indicated below. CR#1 SOC 07/17/2024, CP 07/17/2024 to 09/16/2024 contains a Comprehensive Assessment completed on 07/17/2024. The Emergency Preparedness/Natural Disaster Code noted in the comprehensive assessment is “911” as opposed to a triage classification as noted above. The Triage Determination document was not present in the CR. CR#2 SOC 07/11/2024, CP 07/11/2024 to 09/10/2024 contains a Comprehensive Assessment completed on 07/11/2024. The Emergency Preparedness/Natural Disaster Code noted in the comprehensive assessment is “911” as opposed to a triage classification as noted above. The Triage Determination document was not present in the CR. An interview conducted with the administrator on October 7, 2024 starting at 12:00 PM confirmed the above findings.”

“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 a review of iQIES reports and an interview with the administrator, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the beneficiary for two (2) of two (2) CR’s reviewed: CR#1 and CR#2. Findings include: The HHA’s Patient Information Package reviewed on October 7, 2024 at 9:40 AM reads in part, “Home Health Agencies which participate in the Medicare program are required by the Conditions of Participation to collect and send OASIS date to the Health Care Financial Administration as directed.” A review of iQIES Reports with report run dates of 08/12/2024 (for the time period 01/10/2024 to 08/12/2024) and 09/25/2024 (for the time period 10/10/2023 to 09/25/2024) found that First Hope Home Care Agency Inc. did not have any OASIS Transmittals in 2023 or 2024. A review of the HHA’s census on 10/04/2024 at 9:05 AM found that the agency had two unduplicated skilled admissions in 2024. A review of CR’s was conducted on October 4, 2024 starting at 9:10 AM. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 07/17/2024, CP 07/17/2024 to 09/16/2024. The SOC assessment, completed 07/17/2024, was not transmitted to the CMS system within thirty (30) days of completing the assessment. The patient was a Medicare/Medicaid beneficiary who was receiving skilled services. CR#2 SOC 07/11/2024, CP 07/11/2024 to 09/10/2024. The SOC assessment, completed 07/11/2024, was not transmitted to the CMS system within thirty (30) days of completing the assessment. The patient was a Medicare/Medicaid beneficiary who was receiving skilled services. An interview held with the administrator on October 7, 2024 starting at 12:00 PM confirmed the above findings.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator, the agency failed to provide evidence that a discharge summary was sent to the physician for two (2) of two (2) CR’s reviewed: CR#1 and CR#2. Findings include: The HHA’s Policy Discharge, Transfer and Referral Policy, reviewed on October 7, 2024 at 10:00 AM reads in part, “Following the discharge or transfer of clients, the agency administrator will send a discharge or transfer summary within five (5) business days to the primary care practitioner or other health care professional of the clients who will be providing their services after discharge or transfer from First Hope Home Health Care Agency.” An interview was held with the administrator on October 7, 2024 at 11:55 PM at which time the administrator stated that s/he completes discharge summaries on all patients. A review of clinical records (CR) was conducted on October 4, 2024 starting at 9:10 AM. The Start of Care (SOC), Certification Period (CP) and Discharge Date (DC) are indicated below. CR#1 SOC 07/17/2024, CP 07/17/2024 to 09/16/2024 contained a Notification of Discharge signed by the agency and the patient on 09/18/2024. In addition, an OASIS Recertification/Follow-Up Assessment was completed on 09/18/2024, instead of an OASIS Discharge Assessment. There was no evidence of completion of a discharge summary in the CR, nor that a discharge summary was sent to the physician. CR##2 SOC 07/11/2024, CP 07/11/2024 to 09/10/2024 contained a Notification of Discharge signed by the agency and the patient on 09/12/2024. In addition, an OASIS Recertification/Follow-Up Assessment was completed on 09/12/2024, instead of an OASIS Discharge Assessment. There was no evidence of completion of a discharge summary in the CR, nor that a discharge summary was sent to the physician. An interview with the administrator held on October 7, 2024 at 12:00 PM confirmed the above findings.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) admission documents, and an interview with the administrator, the HHA failed to provide the patient with the names, addresses and telephone numbers of federally-funded and state-funded entities that service the area where the patient resides for two (2) of two (2) CR’s reviewed: CR#1 and CR#2. Findings include: The HHA’s Patient Information Package review on October 4, 2024 at 9:40 AM contained a list of forty-five (45) community resource phone numbers, but failed to list the names, addresses and telephone numbers for the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. A review of CR’s was conducted on October 4, 2024 starting at 9:10 AM. The Start of Care (SOC) is indicated below. CR#1 SOC 07/11/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#2 SOC 07/17/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. An interview conducted with the administrator on October 7, 2024 starting at 12:00 PM confirmed the above findings.”

“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 a review of clinical records (CR), home health agency (HHA) policies, registered nurse (RN) position description, and an interview with the administrator, the agency failed to assure that physician orders were obtained and/or followed for two (2) of two (2) CR’s reviewed: CR#1 and CR#2. Findings include: The HHA’s Policy Medication Profile reviewed on October 4, 2024 at 2:30 PM reads in part, “The medication profile shall include all prescription and over the counter medications. The profile will be updated as needed to reflect current medications the client is taking. All prescription medications taken by the client must be ordered by a physician. If the physician changes the medication orders, the nurse must add newly ordered drugs or medications changes to the medication profile.” The HHA’s Policy Initial Assessment/Patient Admission reviewed on October 4, 2024 at 12:00 PM states in part, “The Comprehensive Assessment will include a review of all medications the client is using. This assessment will identify the potential adverse effects and drug reactions, including ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with therapy.” The HHA’s Policy Physician Order reviewed on October 4, 2024 at 3:00 PM states in part, “Verbal/supplemental orders received between certification periods, orders for minor changes in treatment, changes in drugs, treatments, etc. may be taken by an RN/LVN, written on verbal/supplemental orders form and faxed/sent to the physician office. A copy of the original orders will be filed in the patient’s record. Upon receipt of the signed original supplemental order, the signed copy will be filed in the patient’s medical record. The HHA’s Registered Professional Job Description, reviewed on October 4, 2024 at 2:30 PM reads in part, “A staff nurse performs nursing care functions based on education and skills competency and in accordance with the physician’s orders.” A review of CR’s was conducted on October 4, 2024 starting at 9:10 AM. The Start of Care (SOC) and Certification Period (CP) are indicated below. CR#1 SOC 07/17/2024, CP 07/17/2024 to 09/16/2024 contains a medication order on the Home Health Certification and Plan of Care (POC) for Diphenhydramine (Benadryl - used for allergies) 25 mg (milligrams) CAP (capsule) oral daily prn (as needed). The Medication Profile provided to the patient dated 07/11/2024 states Diphenhydramine 25 mg oral QD (daily) instead of daily, prn. A nurses’ note on 08/06/2024 contains a medication change which reads, “Benadryl 50 mg oral daily.” There was no physician order found in the CR for the change, nor was there evidence that the medication profile was updated and provided to the patient. The POC contains a medication addendum list which has an order for “Insulin Lispro Injection (used to control high blood sugar) 12 units sq (under the skin) three daily.” The Medication Profile, dated 07/17/2024, states the dosage for the Lispro Injection as “12 units subqut TID” (three times a day), but under the frequency column, it states “Q12 hrs” (every 12 hours). The Medication Profile was not updated to clarify the frequency. A nurses’ note on 08/14/2024 contains a medication change which reads, “Ozempic (used to control high blood sugar) 0.5 mg sub injection weekly.” There was no physician order found in the CR for the change, nor was there evidence that the medication profile was updated and provided to the patient. The POC contains physician orders to report a fasting blood sugar greater than 250 or less than 60. Nurses’ notes (2024) on 07/24, 07/31, 08/06, 08/14, 08/21, 08/28, 09/04 show that a “RBS” (routine blood sugar) was checked off on the flowsheet. The FBS (fasting blood sugar) box was unchecked. There was no evidence that fasting blood sugars were being obtained and assessed. CR#2 SOC 07/11/2024, CP 07/11/2024 to 09/10/2024 contains a Medication Profile dated 07/11/2024. The Medication Profile lists Metformin (used to control high blood sugar) 500 mg oral twice daily. A review of the physician orders on the POC do not contain orders for Metformin, nor were any supplemental physician orders found for Metformin. An interview conducted with the administrator on October 7, 2024 starting at 12:00 PM confirmed the above findings.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on a review of clinical records (CR), position description of the registered nurse (RN), and an interview with the administrator, the agency failed to assure that education was provided to the patient regarding high-risk medications for one (1) of two (2) CR’s reviewed: CR#2. Findings include: The HHA’s Registered Professional Job Description, reviewed on October 4, 2024 at 2:30 PM states in part, “Provides skilled nursing care as outlined in the nursing care plan to include the following...teaching, supervising and counseling the client and caregivers regarding the nursing care needs and other related problems of the client at home.” The HHA’s Policy “Medication Profile” reviewed on October 4, 2024 at 2:30 PM reads in part, “the nurse/therapist shall review all medications with the client and/or caregiver to ensure he/she understands how the drugs are to be stored, administered, and is aware of side effects that could be experienced following administration.” A review of CR’s was conducted on October 4, 2024 starting at 9:10 AM. The Start of Care (SOC) and Certification Period (CP) are indicated below. CR#2 SOC 07/11/2024, CP 07/11/2024 to 09/10/2024 found that the CMS Home Health Certification and Plan of Care contained medication orders for Eliquis (a blood thinner) 5 mg (milligrams) oral Q (every) 12 hrs (hours), and ASA (aspirin) 81 mg oral daily. The medication profile contained in the CR which is provided to the patient, completed on 07/11/2024, listed the side effects of Eliquis as bleeding and bruising easily, and Aspirin as gastrointestinal bleeding and ulcers. The medication review in the OASIS (Outcome and Assessment Information Set) Comprehensive Assessment noted via a check-off box that the patient received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants) and how and when to report problems, but the area intended to document the education provided to the patient was blank. The educational needs assessment contained in the Comprehensive Assessment noted “yes” to “medications (refer to medication sheet).” However, there was no documentation specifically related to education concerning the increased risks of bleeding when taking both an anticoagulant and aspirin together on a routine basis. The Comprehensive Assessment Drug Regimen Review which is intended to identify potential/clinically significant medication issues, including drug interactions, found “no problems during review.” There was no evidence to support that the physician was contacted to confirm that both an anticoagulant and aspirin were to be taken on a routine basis. An interview held with the administrator on October 7, 2024 at 12:00 PM confirmed the above findings.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on a review of personnel files (PF), home health agency (HHA) policy, agency documents including meeting minutes and the organizational chart, and an interview with the administrator, the home health agency (HHA) failed to assure that performance evaluations were conducted annually, and by a discipline-specific evaluator for two (2) of five (5) PF’s reviewed: PF#4 and PF#5. Findings include: The HHA’s Policy “Performance Evaluation” reviewed on October 4, 2024 at 1:30 PM reads in part, “First Hope Home Health Care Agency shall endeavor to provide each employee with evaluation upon completion of six months of employment and annually after that. The evaluation shall be job-specific, include the performance of the individual, and if applicable, shall include at least one in-home observation per year for a competency skill check. The appropriate supervisor and department director shall review the performance evaluation with the employee...” The HHA’s documents such as Professional Advisory Committee Meeting Minutes, and other agency meeting minutes reviewed on October 4, 2024 at 1:45 PM listed the performance evaluator for PF#4 and PF#5 as clergy and agency manager, respectively. The HHA’s organizational chart reviewed on October 4, 2024 at 11:00 AM did not contain the name or position of the performance evaluator for PF#4 and PF#5. An interview with the administrator on Monday, October 7, 2024 at 12:00 PM found that performance evaluator for PF#4 and PF#5 was not a registered nurse (RN). A review of personnel files was conducted on October 4, 2024 starting at 11:55 AM. The date of hire (DOH) is indicated below. PF#4 DOH 11/02/2012 is an RN. Performance evaluations and competency assessments completed in 2022 and 2023, and a performance evaluation completed in 2024 were conducted by an individual who was shown in agency documents as an agency manager/clergy and was not an RN as confirmed by the administrator. PF#5 DOH 07/01/2020 is an RN. A performance evaluation and competency assessment completed in 2024 was conducted by an individual who was shown in agency documents as an agency manager/clergy and was not an RN as confirmed by the administrator. There were no performance evaluations or competency assessments contained in the PF for 2022 or 2023. An interview with the administrator on October 7, 2024 starting at 12:00 PM confirmed the above findings.”