Every finding on record at Above and Beyond Home Health Care, Inc

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City Location, the Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for complaint #111054-C from 12/16/24 to 12/23/24. The complaint survey identified the following: Condition of Participation 42 CFR 484.60 Care planning, Coordination of Services and Quality of Care was investigated and no condition level deficiencies were identified and one standard level deficiency was identified (G608). The agency reported a census of 148 at the time of the survey.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on patient interview, agency staff interview, clinical record review and agency policy review, the agency failed to coordinate care delivery to meet the patient's needs of 1 of 5 sampled patients (Patient #4). Failure to ensure staff ordered medical supplies placed agency patients at risk for inconsistent care/treatment. Findings include: According to the agency policy, titled Care Management and Plan of Care, dated 4/15/24, the case manager identifies and notifies appropriate agency management about patient changes including: patient care issues. The individualized plan of care specifies the care and services necessary to meet the needs of the patient identified in the comprehensive assessment and addresses the types of services, supplies, and equipment required. During an interview on 12/23/24 at 10:28 AM, with the Clinical Manager, reported nurses order their own supplies for patients through their tablet. If staff have problems ordering they can reach out to Clinical Manager or Staff C, Education RN (registered nurse), for assistance. Nurses are expected to order additional supplies for patients to ensure patients do not run out of supplies. Patient #4 had a start of care date of 9/18/24 and a discharge date of 11/20/24. Clinical record review revealed: 1.Plan of care, dated 9/18/24 to 11/16/24, included physician orders for skilled nursing services to provide wound care and colostomy management every Monday, Wednesday and Friday. 2. Start of Care comprehensive assessment, dated 9/18/24, included documentation Clinical Manager notified patient will need wound vac supplies, colostomy bags, barrier rings (for colostomy), skin prep and skin powder. During an interview on 12/16/24 at 5:02 PM, Patient #4, reported he/she had very few colostomy supplies, had to wait 10-12 days sometimes to get supplies, had to be out of supplies before he/she could get more supplies. Supplies were ordered for colostomy and patient never received the supplies and had to use cardboard one time because he/she didn’t have the needed colostomy supplies. Colostomy supplies that were received were not correct items or were not a large enough quantity to last the required time frame, would receive 10 colostomy bags but only 1 colostomy ring and had to sometimes change the colostomy ring 3 times a week. 3. Skilled nurse visit note, dated 10/2/24, included documentation patient concerned about ordering more ostomy bags and rings. Supplies ordered today: ostomy bags and rings. 4. Skilled nurse visit note, dated 10/11/24, included documentation supplies ordered today: texted Clinical Manager ostomy bag, barrier rings, skin prep, stoma powder, medipore 4 inch tape, gauze, 8 inch x 10 inch abdominal pads. 5. Skilled nurse visit note, dated 10/16/24, included documentation supplies ordered today: ostomy bags, barrier rings, adhesive remover wipes. 6. Skilled nurse visit note, dated 11/1/24, included documentation supplies ordered today: asked Clinical Manager to order the following: tape, saline, 12 rings (for ostomy), sterile swabs and smaller abdominal pads if available. 7. Skilled nurse visit note, dated 11/6/24, included documentation supplies ordered today: ostomy rings, sterile swabs, tape, saline and attempting to order the 2 piece ostomy bag. 8. Skilled nurse visit note, dated 11/8/24, included documentation supplies ordered today: waiting on shipment of: ostomy rings, sterile swabs, tape, saline, 2 different dressings and attempting to order the 2 piece ostomy bag. 9. Review of the undated Order History Detail Report for the durable medical supply company, included documentation supplies were ordered on the following visit dates: a. 10/10/24, items ordered: barrier strip elastic bravac shaped strip, 1 piece colostomy bag, barrier rings; b. 10/11/24, items ordered: abdominal pads 8 inches x 10 inches, gauze pads, 1 piece colostomy bag, medipore cloth tape, barrier ring extenders, adhesive remover wipe, barrier powder, barrier rings; c. 10/25/24, items ordered:1 piece colostomy bag, paper tape, barrier rings, saline, and packing strips; d. 11/1/24, items ordered: saline, cotton tipped applicator, barrier rings, gauze, cloth tape, adhesive dressing 4 inch x 4 inch, adhesive dressing 6 inch x 6 inch, and 2 piece colostomy bag. The skilled nurse failed to order supplies as documented on 9/18/24, 10/2/24, 10/16/24, 11/6/24 and 11/8/24. During an interview on 12/23/24 at 9:57 AM, Staff A, Administrator reported she was not aware Patient #4 was not receiving their medical supplies. The agency failed to provide the needed medical supplies for the patient care needs.

The combined COVID-19 Focused Infection Control Survey and recertification survey conducted from 10/7/2021 to 10/13/2021, found the agency operating in substantial compliance with the COVID-19 requirements for emergency preparedness and pandemic illnesses. The recertification survey found the agency operating in substantial compliance with the Conditions of Participation for the Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 10/7/2021 through 10/13/2021 . The survey found the agency to be in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements:

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 clinical record review, agency policy review and agency staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral and/or known discharge date, or on the physician ordered start of care date for 2 of 9 sampled patients (Patients #2 and #5). At the time of the survey, the agency reported providing services to 151 patients. Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: According to the agency's undated policy titled, Initial Clinical Visit/Comprehensive Assessment, dated 1/2018, appropriate clinical staff must conduct an initial visit to determine the immediate care and support needs of the patient. The initial visit must be done either within 48 hours of the referral or within 48 hours of the patient's return home from an inpatient stay. If the initial visit is outside the 48 hour window, the agency must enter a Case Communication or note the patient's Admission tab in the electronic medical record noting the reason for the delay and then notify the ordering physician of the inability to meet the 48 hour requirement. During agency staff entrance interviews with the Administrator on 10/7/2021 at 9:25 AM, the Administrator reported she "harps about that" to ensure the visits are made timely. During agency staff entrance interviews with the Clinical Manager on 10/7/2021 at 11:02 AM, the Clinical Manager reported she and/or the Assistant Clinical Manager were responsible for the intake of all new referrals and scheduling of the initial visits within 48 hours. 1. Patient #2 had a start of care date of 4/12/2021. Clinical record review revealed the following: a. The physician's initial referral order, dated 4/8/2021 and sent to the agency by facsimile on 4/8/2021, ordered skilled nursing home health services but did not identify a specific start of care date. b. The Assistant Clinical Manager completed a physician verbal order form on 4/9/2021, documenting the date of verbal order was obtained on 4/8/2021 at 12:00 PM. c. The Plan of Care, dated 4/12/2021 to 6/10/21, identified the start of care date for Patient #2's services was 4/12/1021. d. The clinical record lacked documentation of any skilled nursing visit prior to 4/12/2021 and lacked documentation of any case communication notes or notes within the Admission tab of the electronic medical record for Patient #2 explaining the delay. e. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The patient was not admitted to service until 4 days after receiving the referral. 2. Patient #5 had a start of care date of 8/9/2019. Clinical record review revealed the following: a. The physician's initial referral order, dated 8/5/2019 was entered into the EPIC system and pulled off the system by the home health agency on 8/5/2019. The physician ordered skilled nursing and home health aide services but did not identify a specific start of care date. b. The Plan of Care, dated 8/9/2019 to 10/7/2019, identified the start of care date for Patient #5's services was 8/9/2019. c. The clinical record lacked documentation of any skilled nursing visit prior to 8/9/2019 and lacked documentation of any case communication notes or notes within the Admission tab of the electronic medical record for Patient #5 explaining the delay. d. The clinical record lacked documentation of any follow up with the referring physician to report the delay in initial visit. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The patient was not admitted to service until 4 days after receiving the referral. The above stated findings were reviewed with the Clinical Manager. During agency staff interview on 10/13/2021 at 11:50 AM, the Clinical Manager reported she reviewed the patients clinical records and concurred with the findings. The agency provided no additional information prior to the end of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: 3. Patient #3 had a start of care date of 4/5/19. Clinical record review revealed the following: a. The Plans of Care, dated 7/23/21 to 9/20/21 and 9/21/21 to 11/19/21, included physician orders for Bisacodyl suppository (laxative), polyethylene glycol (laxative) and Sennosides (laxative). b. The Recertifications of care comprehensive assessments, dated 7/22/21 and 9/17/21, included documentation a drug regimen review had been completed but failed to identify the duplicate laxative medications. The nurse failed to accurately complete the drug regimen reviews for Patient #3. The Clinical Manager received the above findings for Patients #3, #6 and #7. The agency provided no additional information prior to the end of the survey. Based on agency policy review, clinical record review and agency staff interviews, the agency failed to identify all duplicate medications taken by patients when performing the drug regimen review comprehensive assessment for 3 of 10 sampled patients (Patients #3, #6 and #7). The agency reported a census of 151 patients at the time of the survey. Failure to ensure medications were reviewed at the time of each comprehensive assessment, using a current and accurate list of medications taken by the patient at the time of the assessment, increased the potential for unidentified medication interactions, patient non-compliance, ineffective medication therapy and side effect risks to the patient. Findings include: According to the agency's undated policy, titled Initial Clinical Visit/Comprehensive Assessment, each initial comprehensive assessment completed at the time of start of care should include a review of all medications taken by the patient, including prescribed and over-the-counter medications. The drug regimen review should identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. According to the agency's undated policy, titled Resumption of Care/Update of Comprehensive, each update to the comprehensive assessment completed at the resumption of care following a hospital stay should include a review of all medications taken by the patient, including prescribed and over-the-counter medications. The drug regimen review should identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. According to the agency's undated policy, titled Drug Regimen Review, a drug regimen review should accompany each comprehensive assessment at the time of resumption of care, recertification and discharge. The drug regimen review should identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. According to the agency's undated policy, titled Drug Regimen Review Therapy Only, for therapy only cases, an office registered nurse will complete the Drug Regimen Review and collaborate with the therapist related to the findings of the review. During agency staff interview on 10/7/2021 at 11:02 AM, the Clinical Manager reported the registered nurses perform a drug regimen review at start of care, recertification, resumption of care following hospitalization and upon discharge from home health services by reviewing all medications taken by the patient, notifying the patient's physician of any concerns identified during the review. The Assistant Clinical Manager completes all of the therapy only drug regimen reviews. 1. Patient #6 had a start of care date of 8/27/2021. Clinical record review revealed the following: a. The Plan of Care, dated 8/27/2021 to 10/25/2021, included orders for docusate sodium (a stool softener) and Miralax (a combined stool softener/laxative). The Miralax contains docusate sodium as a part of the medication. Both medications are taken to treat constipation. b. The drug regimen review completed in combination with the initial comprehensive assessment at the time of start of care, dated 8/27/2021, failed to identify the constipation medications as duplicate medication therapy. 2. Patient #7 had a start of care date of 11/17/2016. Clinical record review revealed the following: a. The Plan of Care, dated 4/25/2021 to 6/23/2021, included orders for bisacodyl suppository (a laxative stool stimulant) and Milk of Magnesia (a laxative). The drug regimen review completed in combination with the update to the comprehensive assessment at the time of recertification, dated 4/23/2021, failed to identify the laxatives as duplicate medication therapy. b. The Updated Plan of Care, dated 5/18/2021 to 6/23/2021, included orders for bisacodyl suppository (a laxative stool stimulant), Milk of Magnesia (a laxative) and Citrucel (a stool bulking agent with softening properties). The drug regimen review completed in combination with the update to the comprehensive assessment at the time of resumption of care, dated 5/17/2021, failed to identify the laxatives as duplicate medication therapy. c. The Plan of Care, dated 6/24/2021 to 8/22/2021, included orders for bisacodyl suppository (a laxative stool stimulant) and Milk of Magnesia (a laxative). The drug regimen review completed in combination with the update to the comprehensive assessment at the time of recertification, dated 6/21/2021, failed to identify the laxatives as duplicate medication therapy. d. The Plan of Care, dated 8/23/2021 to 10/21/2021, included orders for bisacodyl suppository (a laxative stool stimulant) and Milk of Magnesia (a laxative). The drug regimen review completed in combination with the update to the comprehensive assessment at the time of recertification, dated 8/20/2021, failed to identify the laxatives as duplicate medication therapy.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 3 sampled patients requiring a resumption of care assessment (Patient #9). The agency provided services to 151 patients at the time of the survey and performed 19 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the undated agency policy, titled Resumption of Care/Update of Comprehensive, an update to the comprehensive assessment for resumption of care must be completed with in 2 calendar days after the facility discharge date or knowledge of the patients return home. Patient #9 had a start of care date of 7/9/21 and a discharge date of 10/1/21. Clinical record review revealed the update to the comprehensive assessment at the time of resumption of care, dated 8/19/21, documented the patient was discharged from the hospital on 8/18/21. The nurse initiated the update to the assessment on 8/19/21 but did not complete the assessment until 8/22/21, 4 days after the patient's return home from the inpatient stay. The assessment was completed 2 days late as required by regulation and the agency's own policy. The above stated findings for Patient #9 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to update the Plan of Care with interim physician orders for 2 of 7 sampled patients (Patients #8 and #9) with interim orders. The agency reported a current census of 151 patients at the time of the survey. Failure to update the Plan of Care with all interim physician orders received during the certification period increased the potential for medication errors in administration or inaccurate provision of care. Findings include: Review of the agency's undated policy, titled Revised Plan of Care, identified agency staff must develop an individualized plan of care no less frequently than once every 60 days, beginning with the start of care date. The individualized plan of care must be reviewed and revised as frequently as the patient's condition or needs require. 1. Patient #8 had a start of care date of 8/1/21 and a discharge date of 9/8/21. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/1/21 to 9/29/21, included physician orders for physical therapy, occupational therapy and home health aide services. b. Interim physician order, dated 8/5/21 and an effective date of 8/6/21, for an additional home health aide visit. c. Interim physician order, dated 8/31/21, to discontinue home health aide services. The clinical record lacked documentation of updated POC which contained the interim physician orders. 2. Patient #9 had a start of care date of 7/9/21 and a discharge date of 10/1/21. Clinical record review revealed the following: a. The POC, dated 7/9/21 to 9/6/21, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. An interim physician order, dated 7/15/21, for Doxycycline and wound care orders. c. An interim physician order, dated 7/22/21, to continue Doxycycline and start Metronidazole. d. An interim physician order, dated 7/28/21, for insulin orders. e. An interim physician order, dated 7/30/21, to discontinue occupational therapy services. f. An interim physician order, dated 8/2/21, to discontinue physical therapy services. g. An interim physician order, dated 8/3/21, for Mepilex (foam wound dressing) to left shin skin tear. h. An interim physician order, dated 8/24/21, for compression stockings to bilateral lower extremities daily and decrease Amiodarone. i. The POC, dated 9/7/21 to 11/5/21, included orders for skilled nursing, physical therapy and home health aide services. j. An interim physician order, dated 9/29/21, for physical therapy services 1-2 week 2. The clinical record lacked documentation of updated POCs which contained the interim physician orders. The Clinical Manager received the above findings for Patients #8 and #9. The agency provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on clinical record review, personnel file review and agency staff interview: I. the agency failed to ensure 3 of 3 sampled home health aides (Staff I, J and K), demonstrated completion of all of the required basic skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently; and II. the agency failed to ensure 4 of 6 sampled home health aides (Staff H, I, K and L), demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently for 2 patients (Patient #1 and #9). The agency reported a current census of 151, including 88 patients who received home health aide services at the time of the survey. The agency employed 10 home health aides at the time of the survey. Failure to ensure that home health aides demonstrated completion of all of the basic skills successfully while observed by a registered nurse or appropriate therapist prior to caring for agency patients and/or failure to ensure home health aides demonstrated completion of all of the assigned extra skills successfully while observed by a registered nurse or appropriate therapist prior to being assigned to care for patients requiring completion of the task increased the potential risk of harm to the patient.. Findings include: I. Review of personnel file documents and agency staff interview revealed the following: 1. Staff I, Home Health Aide, had a hire date of 9/23/2020. The personnel file included: a. The Initial Competency Assessment Skills Checklist, dated as completed 12/11/2020, documented Staff F, Registered Nurse (RN) evaluated the competency of Staff I, Home Health Aide. The Checklist documented tub bathing in a non-walk in tub was deferred and the aide "will demo prior to performance on a patient". The Checklist lacked documentation of observed competency of shampoo in a tub. Bathing and shampooing in a tub are required as a basic skill and determination of competency is required before the aide cares for any agency patient independently. 2. Staff J, Home Health Aide, had a hire date of 8/16/2019. The personnel file included: a. The Initial Competency Assessment Skills Checklist, dated as completed 10/3/2019, documented Staff F, Registered Nurse (RN) evaluated the competency of Staff J, Home Health Aide. The Checklist documented tub bathing in a non-walk in tub was deferred and the aide "will demo prior to performance on a patient". The Checklist lacked documentation of observed competency of shampoo in a tub. Bathing and shampooing in a tub are required as a basic skill and determination of competency is required before the aide cares for any agency patient independently. 3. Staff K, Home Health Aide, had a hire date of 5/26/2021 and left employment on 10/8/2021. The personnel file included: a. The Initial Competency Assessment Skills Checklist, dated as completed 7/2/2021, documented Staff F, Registered Nurse (RN) evaluated the competency of Staff K, Home Health Aide. The Checklist documented tub bathing in a non-walk in tub was deferred and the aide "was reviewed in classroom and will be supplemental training". The Checklist lacked documentation of observed competency of shampoo in a tub. Bathing and shampooing in a tub are required as a basic skill and determination of competency is required before the aide cares for any agency patient independently. Agency staff interview on 10/13/2021 at 1:15 PM with Staff F, RN, revealed she observes competency of home health aides both with patient's and with pseudo-patients. Staff F, RN, reported the agency did not usually have patients who were safe taking a tub bath so the aides received training for bathing in a tub by her during orientation and she had the aides use a basin to simulate the motions of washing Staff F's hair to satisfy the requirement for tub shampoo. Staff F, RN, reported the occupational therapist also used a box for a tub and trained the aides ahead of time. Then, if the agency gets a patient, the occupational therapist takes the aide to that patient's home to bathe and shampoo the patient in a tub. This is then documented in the system used by the agency for training. Agency staff interview on 10/13/2021 at 2:10 PM with Staff E, Occupational Therapist, revealed she has done competency different ways. The therapist reported using a box in the past and having the aide simulate the task of tub transfer, tub bathing and tub shampooing. Then, if a patient is admitted to the agency that can take a tub bath, the therapist would observe the aides completing all three tasks for competency and document in the system used by the agency for training. Staff E, Occupational Therapist, also reported recently taking the aides to her home and allow the aides to transfer, bathe and shampoo the therapist for competency during orientation; however, Staff E, Occupational Therapist, reported she had not been documenting this competency anywhere in the agency's system. Bathing in a tub and shampoo in a tub cannot be simulated by the home health aide. Both tasks must be performed on a patient or pseudo-patient while observed by a registered nurse or therapist if applicable to the task prior to allowing the aide to care for any home health patients. II. Clinical record review revealed the following: 1. Patient #1 had a start of care date of 10/13/2020. Clinical record review revealed the following: a. The Plans of Care, dated 8/9/2021 to 10/7/2021 and 10/8/2021 to 12/6/2021, included physician orders for skilled nursing and home health aide services. b. The home health aide assignments, dated 8/9/2021 and 10/8/2021, directed the aide to perform urinary catheter care including emptying of the catheter bag; transfer the patient using a mechanical lift and apply a medicated antifungal powder to the patient's groin. c. Urinary catheter care including emptying of the catheter bag; transferring the patient using a mechanical lift and applying a medicated antifungal powder to the patient's groin were assigned as an extension of nursing services, requiring the physician to approve the delegation. d. The clinical record lacked any documentation of physician approval allowing the aide to perform either task as an extension of nursing services. Staff G and H, home health aides were assigned to perform each of the above stated tasks when caring for Patient #1. Personnel file review revealed the following: Staff H, Home Health Aide, had a hire date of 11/14/2013. Staff H's personnel file lacked documentation of satisfactory performance of the tasks of application of a medicated powder and urinary catheter care. 2. Patient #9 had a start of care date of 7/9/2021 and was discharged from agency services on 10/1/2021. Clinical record review revealed the following: a. The Plans of Care, dated 7/9/2021 to 9/6/2021 and 9/7/2021 to 11/5/2021, included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The home health aide assignment, dated 7/9/2021, directed the aide to shave the patient every home visit. Shaving was removed from the assignment on 9/2/2021. Shaving a patient requires extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff L, Home Health Aide, provided care to Patient #9 during the above stated time period. Staff L, Home Health Aide, had a hire date of 11/16/2019 and left employment on 8/31/2021. Staff L's personnel file lacked documentation of satisfactory performance of shaving. c. The home health aide assignment, dated 8/19/2021, directed the aide to perform a simple dressing change. The simple dressing change was removed from the assignment on 9/2/2021. Simple dressing changes require extra skills competency testing prior to assigning the aide to perform the task as an extension of nursing services. The clinical record documented Staff L, Home Health Aide, provided care to Patient #9 during the above stated time period. Staff L, Home Health Aide, had a hire date of 11/16/2019 and left employment on 8/31/2021. Staff L's personnel file lacked documentation of satisfactory performance of simple dressing changes. d. The home health aide assignments, dated 9/2/2021 and 9/17/2021, directed the aide to apply an orthotic boot when dressing the patient. The application of an orthotic boot requires extra skills competency testing prior to assigning the aide to perform the task as an extension of nursing services. The clinical record documented Staff H, I and K, Home Health Aides, provided care to Patient #9 during the above stated time period. Staff H, Home Health Aide, had a hire date of 11/14/2013. Staff H's personnel file lacked documentation of satisfactory performance of the application of an orthotic boot. Staff I, Home Health Aide, had a hire date of 9/23/2020. Staff I's personnel file lacked documentation of satisfactory performance of the application of an orthotic boot. Staff K, Home Health Aide, had a hire date of 5/26/2021 and left employment on 10/8/2021. Staff K's personnel file lacked documentation of satisfactory performance of the application of an orthotic boot. The above stated findings for Patients #1 and #9 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 3 of 3 sampled patients receiving home health aide services with extra skills assigned (Patients #1, #7 and #9). The agency reported a current census of 151 patients at the time of the survey. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: Review of the undated agency policy, titled Assignment and Duties of the Hone Health Aide, identified written patient care instructions for the home health aide must be prepared by the registered nurse or appropriate therapist. The home health aide provides services that are listed on the patient specific aide care plan and ordered by the physician on the 485. The duties listed on a home health aide care plan, may include the provision of hands-on personal care and performance of simple procedures as an extension of therapy or nursing services. 1. Patient #9 had a start of care date of 7/9/21 and a discharge date of 10/1/21. Clinical record review revealed the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for skilled nursing, physical therapy, occupational therapy services, and home health aide services to assist with/provide personal care services, light housekeeping, uses cane, walker, shower chair, and may take oxygen off in shower. b. Home health aide assignment, dated 7/9/21, included instructions for the aide to assist the patient with shaving. The POC lacked documentation the aide would provide the extra skill task of shave. c. Home health aide assignment, dated 8/19/21, included instructions for the aide to assist the patient with shaving and apply simple dressing of gauze over wound to right foot after shower, secure with wrap. The POC lacked documentation the aide would provide the extra skill tasks of shave and simple dressing change. 2. Patient #1 had a start of care date of 10/13/2020. Clinical record review revealed the following: a. The Plans of Care, dated 8/9/2021 to 10/7/2021 and 10/8/2021 to 12/6/2021, included physician orders for skilled nursing and home health aide services. b. The home health aide assignments, dated 8/9/2021 and 10/8/2021, directed the aide to perform urinary catheter care including emptying of the catheter bag; transfer the patient using a mechanical lift and apply a medicated antifungal powder to the patient's groin. c. Urinary catheter care including emptying of the catheter bag; transferring the patient using a mechanical lift and applying a medicated antifungal powder to the patient's groin were assigned as an extension of nursing services, requiring the physician to approve the delegation. d. The Plans of Care, dated 8/9/2021 to 10/7/2021 and 10/8/2021 to 12/6/20213, included physician orders for the home health aide using a mechanical lift for patient transfers; however, lacked inclusion of catheter care/emptying the catheter bag and the application of the medicated powder as interventions for the aide. e. The clinical record lacked any documentation of physician approval for the aide to perform either task as an extension of nursing services. Staff G and H, home health aides were assigned to perform each of the above stated tasks when caring for Patient #1. 3. Patient #7 had a start of care date of 11/17/2016. Clinical record review revealed the following: a. The Plans of Care, dated 4/25/2021 to 6/23/2021, 6/24/2021 to 8/22/2021 and 8/23/2021 to 10/21/2021, included physician orders for home health aide services without the provision of a skilled service. b. The home health aide assignments, dated 4/23/2021, 6/21/2021 and 8/20/2021, directed the aide to shave the patient every home visit. Shaving a patient requires physician approval to approve the delegation of the task. c. The Plans of Care, dated 4/25/2021 to 6/23/2021, 6/24/2021 to 8/22/2021 and 8/23/2021 to 10/21/2021, lacked documentation of the task to shave the patient an intervention for the aide. d. The clinical record lacked any documentation of physician approval allowing the aide to perform the task as an extension of nursing services. The clinical record documented Staff N, Home Health Aide, routinely shaved Patient #7 during home health visits. The above stated findings for Patients #1, #7 and #9 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.