Every finding on record at Active Home Health Care Serv

Substantial Allegation Survey conducted for complaint #212522/IL 00134439. Standard level deficiencies cited. Abbreviations: x = times # = number w/WK = week eval = evaluate AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients HEP = Home Exercise Program ST = Speech Therapy/Therapist PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provided services, as indicated in the POC. This was found in 2 of 2 (Pts. #1 and 2) closed clinical records reviewed. Findings include: 1. Pt. #1. SOC 4/6/21. Primary Diagnosis: Hemiplegia and Hemiparesis following Nontraumatic Intracerebral Hemorrhage Affecting Left Non-Dominant Side. The clinical record was reviewed on 6/22/21 at 3:15 PM. The record contained the POC for the certification period of 4/6/21 to 6/4/21 requiring: "ST Frequency: Evaluation and Management". The ST evaluation dated 4/14/21 included: "Visit Frequency 1WK1, 0WK1, 1WK4." The record lacked documentation that the ST provided service during the week of 5/2/21 to 5/8/21. 2. Pt. #2. SOC 3/25/21. Primary Diagnosis: Primary Generalized (Osteo) Arthritis. The clinical record was reviewed on 6/22/21 at 2:30 PM. The record contained the POC for the certification period of 3/25/21 to 5/23/21 requiring: "SN Frequency; PT Frequency: Evaluation and Management Eval and follow and establish HEP with safety precautions..." The PT evaluation dated 3/26/21 required the PT to provide service "1w6". The record lacked documentation the SN and PT provided any service during the week of 4/18/21 to 4/24/21. The POC effective 3/25/21 required: "SN to provide skilled assessment... assess, manage and mitigate pain..." The SN visit note dated 5/15/21 lacked documentation the SN assessed the Pt. for pain. 3. During an interview with the Administrator and Director of Nursing on 6/22/21 at 3:35 PM, the Administrator and Director of Nursing confirmed, staff failed to provide service as indicated in the POC.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff complied with Physician orders. This was found in 1 of 3 (Pt. #2) clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/25/21. Primary Diagnosis: Primary Generalized (Osteo) Arthritis. The clinical record was reviewed on 6/22/21 at 2:30 PM. The record contained the "Resumption of Care Order" completed by the SN, dated 5/6/21 and signed by the Physician. The order included, "Services frequency/description: SN 1w3, PT: Evaluation and Management - to eval and follow and establish HEP with safety precautions. The record lacked documentation the SN provided service after 5/15/21, and that the PT provided any service after the resumption of care visit on 5/6/21. 2. During an interview with the Administrator and Director of Nursing on 6/22/21 at 3:35 PM, the Administrator and Director of Nursing confirmed, staff failed to comply with Physician orders.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA 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). This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to develop a discharge plan with the Pt./family and the Physician, prior to the Agency's discharge. This was found in 1 of 2 (Pt. #2) closed clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/25/21. Primary Diagnosis: Primary Generalized (Osteo) Arthritis. The clinical record was reviewed on 6/22/21 at 2:30 PM. The record contained the Resumption of Care comprehensive assessment completed by the SN and dated 5/6/21. The assessment included documentation the Pt. was discharged from the hospital on 5/3/21 with a diagnosis of "Unilateral Primary Osteoarthritis, Left Hip". The assessment included, "Discharge Patient When: Patient demonstrates necessary skills to manage disease process...Pain level stabilizes and patient demonstrates ability to self-manage pain." The record lacked documentation the PT provided any service after the resumption of care visit on 5/6/21. The last SN visit was conducted on 5/15/21 which lacked a pain assessment and discharge planning. The Agency discharged the Pt. on 5/22/21. The record lacked any documentation of discharge planning to ensure post discharge, continuation of services would be coordinated with another Agency. The physician was not notified of the Agency's discharge until 5/22/21. 2. The Agency's policy titled, "Client Discharge Process" was reviewed on 6/22/21 at 2:50 PM. The policy required: "...2. Client's needs for continuing care to meet physical... needs are identified and clients are told in a timely manner (3 consecutive visits) of the need to plan for discharge or transfer to another level of care/organization. Clients are informed of the reason for discharge and anticipated needs for services after discharge... 5... A Discharge Plan shall be developed that is documented in writing and includes all written/verbal instruction regarding the client's ongoing care needs and available resources provided to the client and family... 9. To avoid charges of "abandonment" at the time of discharge... documentation will include the following: a. Evidence that the decision was not made unilaterally. The client, family and physician participated in the decision to discharge client.." 3. During an interview with the Administrator and Director of Nursing on 6/22/21 at 3:35 PM, the Administrator and Director of Nursing confirmed, the Agency staff failed to develop a discharge plan with the Pt./family, and the Physician prior to discharge.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure there was coordination of care between interdisciplinary staff to ensure Pt. needs were met. This was found in 1 of 3 (Pt. #2) clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/25/21. Primary Diagnosis: Primary Generalized (Osteo) Arthritis. The clinical record was reviewed on 6/22/21 at 2:30 PM. The record contained the POC for the certification period of 3/25/21 to 5/23/21 which contained: "Goals... Patient will have improved gait and balance, increased muscle strength without complication/ fall/ injury by the end of the certification period..." The PT evaluation dated 3/26/21 (Friday), weekly PTA visit notes dated 4/1/21 (Thursday) and 4/8/21 (Thursday), and the PT reassessment dated 4/15/21 (Thursday), all included documentation the PT or PTA provided service. The record contained documentation the SN attempted to visit the Pt. weekly on 4/3/21 (Saturday), 4/10/21 (Saturday) and 4/17/21 (Saturday), these attempted visits were documented on "Missed Visit" notes which included: "No answer to phone call..." The record lacked documentation that interdisciplinary staff and the physician was notified of the missed visits.. 2. The Agency policy titled, "Coordination of Client Services" was reviewed on 6/22/21 at 3:00 PM. The policy required: "...Purpose To ensure services are coordinated between members of the interdisciplinary team... To assure that efforts of...personnel effectively complement one another and support the objectives outlined in the Plan of Care... 4. Ongoing care conferences shall be conducted to evaluate the client's status and progress. Any problems will be discussed and an action plan developed..." 3. During an interview with the Administrator and Director of Nursing on 6/22/21 at 3:45 AM, the Director of Nursing stated, in April 2021 the Agency received a phone call from a family member, requesting the SN provide service on a weekday. The Pt./family does not want weekend visits. The DON stated the Agency lacked nursing staff to service the patient on weekdays, and was unable to accommodate the Pt./family. The Administrator stated the business hours of the Agency is Monday through Friday (9:00 AM to 5:00 PM). During the same interview, the Administrator and the Director of Nursing confirmed the Agency failed to coordinate services among the disciplines, and notify the physician of the scheduling conflict, until the Agency discharged the Pt. on 5/22/21.