Empathy Home Health Services Inc.

“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 record reviews and interview, the agency failed to ensure that the plan of care was followed as ordered by the physician for 1 of 8 patients (patient #6) whose records were reviewed; in that The agency failed to ensure the home health aide visits were performed as indicated in the plan of care for patients receiving home health aide services. This failure placed the patients at risk of not receiving the services needed and has the potential for patient dissatisfaction regarding services and health status deterioration. Findings include: Patient #6 Record review of patient #6’s CR included a POC for the certification period of 08/23/24 to 10/21/24 and a SOC date of 06/24/24. The POC showed a primary diagnosis of Osteoarthritis (bone disease), secondary diagnosis of Essential (Primary) Hypertension (Blood Pressure), Generalized anxiety disorder, and unsteadiness on the feet among other diagnosis. The POC Orders for disciplines include SN one time a week for 5 weeks and 4 PRN visits, HHA zero time a week for 1 week, two times a week for 8 weeks. Further review of the record indicated that the patient received services for approximately three weeks before being discharged on 09/09/24 and the HHA services were not provided during the certification period before the patient was discharged. The CR revealed that the HHA did not perform any visits as indicated in the plan of care for a patient who was ordered home health aide services in the POC. During an interview on 10/14/24 at 2:50 p.m. with the Administrator/Supervising Nurse, the surveyor presented the above findings and asked about the personnel responsible for ensuring the POC was being followed as ordered. The Administrator/Supervising Nurse said the Supervising Nurse was responsible and ensured that the POC orders are being followed. The surveyor further asked why the agency failed to ensure that the HHA visits were performed as indicated in the plan of care for a patient whose order included a home health aide service. The Administrator/Supervising Nurse said he was sure that the home health aide services were provided and could probably be that the notes were misfiled. The surveyor asked the Administrator/Supervising Nurse to go search for the HHA visit notes since they were being misfiled. The Administrator/Supervising Nurse stepped into his office and came back after a while without the HHA visit notes and said he could not find the notes. Record review of the undated agency policy titled “Policy: Plan of Care/Services” page 2 of 4 read in part; “...3) Care or services are provided at the appropriate frequency identified or on the days and at the times scheduled with the client…” Record review of additional undated agency policy titled “Policy: Home Health Aide: Documentation” read in part; “…4) The original documentation shall be filed in the clinical record within fourteen (14) days of the end of the recording period…””

“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 reviews and interview, the agency’s registered nurse failed to make an onsite visit to patients’ home to supervise the Home Health Aide no less frequently than every 14 days for 2 of 2 patients (patient #6 and #8) in which home health aide services were provided for more than 14 days. This failure places the agency’s patients at risk of not receiving safe and effective care from the aide and could cause complications and/or decline in health status. Findings include: Patient #6 Record review of patient #6’s clinical record (CR) showed a POC with a SOC on 06/24/24 for the certification period 06/24/24 - 08/24/24. The POC showed a primary diagnosis of Osteoarthritis (bone disease), secondary diagnosis of Essential (Primary) Hypertension (Blood Pressure), Generalized anxiety disorder, and unsteadiness on the feet among other diagnosis. The POC Orders for disciplines include SN one time a week for 5 weeks and 4 PRN visits; HHA two times a week for 1 week, three times a week for 8 weeks; PT to evaluate and treat but was placed on hold effective 07/03/24 with a doctor’s order for the hold. The record review of the HHA notes revealed that HHA services followed the frequencies of two times a week for 1 week, three times a week for 8 weeks as per the POC for the certification period. The record review of the SN notes revealed that SN services followed the frequencies of one time a week for 9 week which included the 4 PRN visits as per the POC for the certification period. Further review of the SN visit notes showed that the agency used a nursing visit note that has the supervisory visit on page 2 of the nursing visit note. Record review of the page 2 of the SN visit notes showed that the Administrator/Supervising Nurse did all the SN visits and there was no aide supervision done throughout the certification period. The page with the aide supervision section was checked “N/A” (not applicable) on all the SN notes for the entire certification period. Patient #8 Record review of patient #8’s clinical record (CR) showed a POC with a SOC on 03/24/23 for the certification period 09/20/23 - 11/18/23. The POC showed a primary diagnosis of Alzheimer’s disease (brain disease), secondary diagnosis of Essential (Primary) Hypertension (Blood Pressure) among other diagnosis. The POC Orders for disciplines include SN one time a week for 9 weeks and 4 PRN visits, HHA zero time a week for 1 week, and two times a week for 8 weeks. The record review of the HHA notes revealed that HHA services followed the frequencies of zero time a week for 1 week, two times a week for 8 weeks as per the POC for the certification period. The patient was discharged from the agency on 11/07/23 before the end of the certification period. The last HHA service was provided on 11/03/23 before the patient was discharged on 11/07/23. The record review of the SN notes revealed that SN services followed the frequencies of one time a week as per the POC for the certification period before the patient was discharged on 11/07/23. Further review of the SN visit notes showed that the agency used a nursing visit note that has the supervisory visit on page 2 of the nursing visit note. Record review of the page 2 of the SN visit notes showed that the Administrator/Supervising Nurse did all the SN visits and there was no aide supervision done throughout the certification period. The page with the aide supervision section was checked “N/A” (not applicable) on all the SN notes for the certification period before the patient was discharged on 11/07/23. During an interview on 10/14/24 at 2:40 p.m. with the Administrator/Supervising Nurse, the surveyor presented the above findings. The Administrator/Supervising Nurse stated, “We did the Aide supervision and if it’s not on the patient’s clinical record at this time, then it’s possible we misfiled it.” The surveyor further asked the Administrator/Supervising Nurse if the agency had a separate form for the aide supervision that was misfiled. The Administrator/Supervising Nurse did not answer the question and kept quiet. Record review of the undated agency policy titled “HR.12 Employee Supervision “ read in part; “…1)...If home health aide services are provided to a patient/client who is receiving skilled nursing, physical therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient/client, the patient’s/client’s plan of care, and the written patient/client care instructions, must make an onsite visit to the patient’s/client’s home no less frequently than every fourteen (14) days. The home health aide does not have to be present during the visit…””