Alpha Care Health Services of WI, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure Home Health Agency federal and state regulations were followed in 1 of 1 Home Health Agency reviewed. Findings include: The agency failed to complete a thorough discharge summary for 1 of 1 discharged patients reviewed (Patient #1). See tag G0464. The cumulative effect of this systemic problem resulted in the home health agency’s inability to ensure all patients understood their rights.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure Home Health Agency federal and state regulations were followed in 1 of 1 Home Health Agency reviewed. Findings include: The agency failed to ensure patient plans of care were reviewed at least every 60 days for 4 of 4 patient (Patients #1, 2, 3, 4) records reviewed. See tag G0588. The cumulative effect of this systemic problem resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure Home Health Agency federal and state regulations were followed in 1 of 1 Home Health Agency reviewed. Findings include: The agency failed to ensure certification procedures were followed to admit skilled patients. See tag G0942. The cumulative effect of this systemic problem resulted in the home health agency’s inability to ensure oversight of management and agency.”

“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’s governing body failed to maintain oversight of the agency to ensure certification procedures are followed to admit skilled patients in 1 of 1 program census reviewed. (Governing Body.) Findings include: Record review of agency total active census revealed 111 unskilled patients (40 personal care and 71 supportive care) and 1 skilled patient. Record review of skilled patient census revealed 1 skilled patient (Patient #3) with a start of care of 05/14/2024. Record review of skilled patient admissions for the past 12 months revealed 1 admission. (Patient # 3) Record review of agency skilled patient referrals since 01/01/2024 revealed 38 total referrals and 37 declined referrals. During an interview with Administrator B on 09/13/2024 at 10:10 AM, when asked for the reason skilled referrals were declined, Administrator B stated, “Most referrals are not coming directly to us but coming into a pool that different home health agencies can choose to take on.” Administrator B states, “Since it has been over a year since the agency has had skilled patients, we (Agency) wanted to make sure were following all regulations and doing it right, so we are taking on skilled patients again slowly.” When asked what the agency plan is to increase skilled patient census, Administrator B stated, “We have a board meeting this month and this was a topic of discussion.” Administrator B stated that there is no date set for this board meeting at this time.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, agency staff failed to complete a 30-day summary, which includes a date of discharge, a description of the care provided, reason for discharge and any referrals to alternate providers for continued services, in 1 of 1 discharged record reviewed. (Patient #1) Findings include: Review of policy “Discharge Criteria and Planning”, revealed in part, “Patients will be discharged from services as follows: 2. the patient’s behavior is disruptive, abusive, or uncooperative to the extent delivery of care or the ability of the agency to operate effectively is seriously impaired, the agency will discharge for cause. The agency will do the following prior to discharging for cause. a) Advise the patient and physician ordering the home health plan of care and other health care providers who will provide care after discharge, that a discharge for cause is being considered. b) Provide the patient with contact information of other providers who may be able to provide care. c) Document the problems, behaviors that warranted discharge for cause and efforts made to resolve the problems, in the clinical record. d) In extreme situations with serious imminent threat of harm to agency staff, agency may discharge immediately. Document the behavior or threat supporting immediate harm. e) Evidence in the record that the agency provided the patient with contact numbers for other community resources and other agencies that could provide services. 6. The patient’s continuing care needs are assessed at discharge. 9. Patients are informed prior to discharge of plans for discharge and the reason for discharge.” Review of Patient #1’s medical record revealed Patient #1 was discharged from home care services on 08/07/24. Reason for discharge on the discharge notification form was “staff safety.” Review of a communication note dated 08/07/2024 revealed reason for discharge “Medicaid Fraud.” There was no documentation within the record that supported either reasons for discharge or that a written notice of pending discharge was given to the patient or ordering Physician prior to discharge. There was no documentation within the clinical record that a Summary was completed in 30-days following discharge, which included the date of discharge, a description of the care provided, reason for discharge and contact numbers for community resources or other agencies per the agencies policy and procedures. During an interview with Administrator B on 09/03/2024 at 3:05 PM, when asked if there was any additional documentation supporting the discharge of patient #1 for staff safety, Administrator B replied. ”there was concern for staff safety,” no additional documentation was found in the clinical record. When asked if per agency policy and procedure “a discharge evaluation was done, a discharge summary was completed and if any contact numbers were given to the patient for continued care,” Administrator B stated, “we sent the discharge notice to the patient and ordering Physician.” During an interview on 09/03/2024 at 3:22 PM, Administrator B stated “I (Administrator B) was under the impression and told supportive care and personal care follow their own regulations and program guidelines.””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, agency staff failed to ensure that patient’s Plans of Care were reviewed by the Physician no less often than every 60 days in 4 of 4 patient records reviewed. (Patients #1, #2, #3 and #4). Findings include: Review of policy “Plan of Care” not dated revealed in part, “The care plan is reviewed and/or revised, with physician participation, at least every 60 days.” Review of Patient #1’s “Home Health Plan of Care and Certification” revealed a start of care date 01/29/2024 and certification period dates of 01/29/2024-01/30/2025. This is a total of 365 days. There is no documentation within the record that the physician reviewed the Plan of Care on or before 03/28/2024, 05/27/2024 or 07/27/24, which would have been every 60 days. Review of Patient #2’s “Home Health Plan of Care and Certification” revealed a start of care date 09/02/2022 and the certification period dates of 08/27/2023--08/28/2024 which is a total of 371 days. There is no documentation within the record that the physician reviewed the Plan of Care on or before 10/26/2023, 12/25/2023 or 02/27/24, 04/26/2024, 06/26/2024, or 08/27/2024, which would have been every 60 days. As of 09/03/2024 the current “Home Health Plan of Care and Certification” expired on 08/28/2024. Review of Patient #3’s “Home Health Plan of Care and Certification” revealed a start of care date 05/14/2024 and a certification period date of 07/13/2024—no date. This is a total of 115 days. There is no documentation within the record that the physician reviewed the Plan of Care on or before 07/14/2024 or to date 09/03/2024, which would have been every 60 days. As of 09/03/2024 the current “Home Health Plan of Care and Certification” expired on 07/12/2024. Review of Patient #4’s “Home Health Plan of Care and Certification” revealed a start of care date 12/21/2020 and certification period dates of 12/21/2020--02/18/2021. This is the only physician signed “Home Health Plan of Care and Certification” found in the medical record. There is a total of 1,293 days between 02/18/2021—09/03/2024. There is no documentation within the record that the physician reviewed the Plan of Care every 60 days after 02/18/2021. During an interview with Administrator B on 09/03/2024 at 2:20 PM, when asked if there were current physician orders, Administrator B replied “no, what you have is all we have. The plan of care is determined by the authorizing entity.” During an interview on 09/03/2024 at 3:22 PM, Administrator B stated “I (Administrator B) was under the impression and told supportive care and personal care follow their own regulations and program guidelines.””

“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 provide Registered Nurse (RN) supervision to the Licensed Practical Nurse (LPN) services provided in 4 (Patient #1, #3, #6, #7) out of 5 patients receiving LPN services in a total of 7 records reviewed. During an interview with Administrator A on 07/09/2024 at 3:30 PM, when asked how often the RN is expected to supervise the LPN, Administrator A replied, “The LPN is supervised every 30 days.” When asked for a policy for RN supervision of the LPN, Administrator a replied, “I don’t have a policy that states how often. We have stand up meetings every morning that discusses patients but doesn’t really have formal supervision documented.” Record review of Administrator A documented stand up meetings dated 12/2021 to 08/2022 revealed no evidence of LPN supervision by the RN. Record review for Patient #6 “Home Health Certification and Plan of Care” orders dated 12/14/2022 – 02/11/2023 revealed “SN frequency: 2 times a week for 1, 3 times a week for 8 and 3 as needed visits.” The LPN conducted home visits 1 to 3 times weekly for the weeks of 12/14/2022 to 01/08/2023. There was no documented evidence of LPN supervision completed by the RN every 30 days during this timeframe. Record review for Patient #7 “Home Health Certification and Plan of Care” orders dated 05/14/2024-07/12/2024 revealed “SN frequency: 3 times a week for 8 and as needed visits.” The LPN conducted home visits 1 to 3 times weekly for the weeks of 05/14/2024 to 07/08/2024. There was no documented evidence /of LPN supervision completed by the RN every 30 days during this timeframe. Findings include: Record review of Patient #1’s “Home Health Certification and Plan of Care” orders dated 11/09/2022 – 01/07/2023 revealed “SN (Skilled Nurse) frequency: 1 time a week for 1, 2 times a months for 2, and 3 as needed visits.” The LPN conducted home visits on 11/22/2022 and 12/06/2022, and there was no documented evidence of LPN supervision by the RN every 30 days from 11/22/2022 until the day of patient discharge 01/07/2023. Record review for Patient #3 “Home Health Certification and Plan of Care” orders dated 12/09/2022 – 02/06/2023 revealed “SN frequency: 1 time a week for 1, 3 times a week for 8 and 3 as needed visits.” The LPN conducted home visits 1 to 3 times weekly the weeks of 12/11/2022, 12/18/2022, 12/25/2022, and 01/01/2023. There was no documented evidence of LPN supervision completed by the RN every 30 days during this timeframe.”