Every finding on record at Adventhealth Home Health and Hospice, Inc

During the Home Health Survey conducted February 15-17 2021, Emergency Preparedness was reviewed at Advent Health Home Care and was in compliance per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

An unannounced recertification survey and infection control focus visit was conducted February 15-17 2021 in Ormond Beach, Florida. The home health agency was not in compliance with Code of Federal Regulations (CFR) 42,, Part Part 484.22, Condition of Participation for Home Health Agencies. .

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to issue a written Notice of Medicare Non-Coverage prior to discontinuance of services for 1 of 6 patients receiving Medicare skilled services from total sample of 20 patients. (Patient #4). The findings include: Record review for Patient #4 revealed 66 year old female with Start of Care on 10/18/20. Her diagnosis included: Sepsis, Covid19, viral pneumonia, acute respiratory failure with hypoxia, metabolic encephalopathy, diabetes, end stage renal disease with dialysis 3 times a week. Plan of Care (POC) included Skilled Nurse (SN) 2wk4 and 1wk5. Physical Therapy(PT) evaluate and treat. On 10/28/20, she was transferred to the hospital for respiratory distress. She was not discharged from the agency. She returned home on 11/2/20 with resumption of care on 11/3/20. The POC included PT 2wk3. Review of the PT notes revealed Patient #4 was discharged from services on 11/28/20. There was no written notice of Medicare non coverage found in the record. An interview was conducted with the Clinical Manager on 2/16/21 at 11:22am. She confirmed that the notice for Medicare Non-Coverage had not been given to Patient #4. Review of the agency policy Medicare Notices included: the home health agency is required to notify the Medicare beneficiary in writing of reductions and terminations in the plan of care. The Notice of Medicare Provider Non-Coverage will continue to be issued at least 48 hours prior to termination of all covered services prior to patient discharge. .

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of patient complaints and staff interviews, the agency failed to document resolution and follow up to patient complaints for 3 of 3 sampled patient complaints from a total sample of 20 patients. (Patient # 18, 19, 20). The findings include: 1. Review of complaint filed by Patient #18 on 5/11/20 revealed that she called the agency and requested a different therapist. Patient #18 reported that the therapist yelled at her and was very unprofessional. The complaint was investigated by the Therapy Director (TD). Review of the complaint investigation revealed the intervention was to provide education to the staff member. Further review of the report found there was no documentation of resolution or follow up with the patient. 2. Review of complaint filed by spouse of Patient # 19 on 2/11/20 revealed the patient and spouse reported a difficult session with Physical Therapist (PT) the previous week, The PT had some issues on entering the home regarding the patient and spouse not wearing masks. The spouse felt he was a bit abrupt and slightly over the top with his reactions to them. The spouse felt the patient responded poorly during the therapy session at the time and are requesting another therapist. Review of the investigation report included the intervention was follow up with client/caregiver. There was no resolution or follow up documented. 3. Review of complaint regarding Patient # 20 on 12/28/20 revealed the spouse called and requested the Physical Therapy Assistant not return to provide services. The spouse stated when he saw that she did not have a mask on, he put his hands up and backed out of the home. He put on two masks, face shield and gloves. During the visit the PTA made them feel like they had the plague. Review of the investigation revealed the intervention was to follow up with client/caregiver. Further review of the report found there was no documentation of resolution or follow up with the patient. An interview was conducted with the Therapy Director on 2/16/21 at 11:30 am. She was asked if she had conducted the investigations of the complaints, for Patients 18, 19 and 20. She said she had. She was asked if she documented resolutions or follow up with complainants, she said she spoke to them on the phone but did not document on the complaint reports, Review of the agency policy "Compliant/Grievance Process revealed the following: the agency personnel receiving the complaint will discuss verbally and in writing, the grievance with the Clinical Supervisor within 5 days of the alleged grievance. The Clinical Supervisor will investigate the grievance within 5 days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within 10 days of receipt. A written response to notify patient of resolution and follow up. .

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: Based on record review and staff interview, the agency failed to identify all medications prescribed by the physician and update the medication profile record for 2 of 20 sampled patients. ( Patients # 11, 13,). The findings include: 1. Record review for Patient #11 revealed 82 year old male with Start of Care date 1/22/21. His diagnosis included: Epilepsy, malignant neoplasm of brain and cerebral edema. The Plan of Care (POC) included Skilled Nurse (SN) 1 wk 1, 2 wk 6, 1 wk 6. Physical therapy (PT) 2 wk 6 and Occupational Therapy (OT) 2 wk 3. The POC included the following medications: Dexamethasone 2 mg daily, Levetiracetam 500 mg twice daily and Rabeprazole 20 mg daily. Review of the case conference note dated 1/24/21 revealed the wife had called and stated her husband would restart oral chemotherapy drug tomorrow for 5 days. There was no documentation in the record of what drug he would receive nor the medication profile updated to include the additional medication. During an interview on 2/17/21 at 10:40 am with the Clinical Manager (CM), she was asked if an oral chemotherapy medication was ordered for Patient #11. She reviewed the medication profile and did not find any oral chemotherapy medications. She said she would review the orders. She said she did find the order on 1/25/21 to restart Temozolomide 100 mg 3 capsules x 5 days. She said the medication had not been updated in the medication profile. Review of the agency policy Medication Profile included: for accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon entry to the organization. A comparison of the medications ordered for the patient while under the organizations care will be made on the list. 2. Client #13 is a 90 year old man who lives with his 90 year old wife, and who was previously independent with all his activities of daily living, but who had a recent cerebral infarct along with cellulitis of his upper right limb, for which he was referred to Home Health services on 1/24/2021, for SN, PT, OT for management of his pain , health teaching, mobility and fall prevention. Client physician orders at admission on 1/24/2021 does not document any prescribed pain medication. Visit record of 1/25/2021 and 1/27/2021 documented client's pain but no updating of clients medication profile. Visit record for 1/26/2021 documented client#13 pain score and clinician noted that client had on a Lidocaine patch but there is no record of which physician prescribed this patch nor was this Lidocaine patch updated on client's medication profile. Visits by varying disciplines on 1/26/21, 1/28/2021, 1/30/2021, 2/1/2021, 2/2/2021,2/4/21, 2/5/2021, 2/12/2021 indicated that medication reconciliation was done but still clinicians had not updated medication record with client's Lidocaine patch. In an interview on 2/17/2021 at 1:43 PM, with the Clinical Coordinator for nursing, she was asked how often medication reconciliation was done. She stated medication reconciliation was supposed to be done at each visit. She stated that staff were supposed to add new orders, add or discontinue medication that they have seen, and they should be looking at all the bottles in the home or packs. She was asked if staff had at any time documented in the medication records that Client#13 was using a Lidocaine patch. She attested that Lidocaine patch was observed on client, but clinicians failed to update it on the client's medication profile. .

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to adequately communicate clients changing needs in the areas of pain management, psychosocial needs to the physician for possible reassessment and referral for additional services for 4 Patients (#6, 7, 13, 16) out of a sample of 20. Findings include: 1. Client #6 is a 71-year-old who was diagnosed with severe venous insufficiency with a deep non-pressure chronic ulcer of the left ankle that had the fat layer exposed. She also had cellulitis in the left lower limb and was experiencing pain. She was also morbidly obese which made it very difficult to ambulate and perform her activities of daily living. Client #6 had a fall at home where she scraped the leg and was referred for home health services on 1/7/2021, for skilled nursing services for medication management, wound care, assessment, and review of effectiveness of pain management. Review of client's medication orders at the time of her admission to home health services revealed Client #6 had no pain medication ordered. Review of the comprehensive assessment done on 1/7/2021 revealed that client indicated that her activities including her ability to leave home was restricted due to her pain. She indicated that she was experiencing pain in her neck and lumbar region. The record revealed that on a numeric scale of 0 no pain and 10 most pain, her scoring of pain she experienced was a 5. Client #6 also indicated feelings of depression and sense of hopelessness over several days. It was documented in the narrative note, "please assess living situation on future visit" but facility had no social worker to perform psychosocial assessment. Review of visit note record on 1/11/2021 revealed that Client #6 pain had increased and was now scored on the numeric scale as a 7. The narrative note indicated client's house "was cluttered, crowded and she was advised on removing clutter." There was no indication in the record that physician was contacted on client's need for additional services such as home health aide to assist client to remove clutter, or need for social services referral to assess social environment and support for client. Client's pain had increased from 5 to a score of 7 but this was not communicated to the physician so that client's pain could be addressed. Review of visit note record on 1/13/2021. Client expressed her pain level as a 7 out of 10 ,the narrative documented pain level and wound care, but again no communication with physician to attempt to gain pain relieving medication for Client #6. Review of visit note of 1/15/2021 revealed Client #6 pain level was a 6 out of 10 and documented client as feeling "down, discouraged and weepy." In the coordination section of the visit note for 1/15/2021 the clinician indicated that she communicated to the Registered Nurse (RN) but no communication was made to the physician. The narrative note indicated client 'felt alone, weepy', discussed options to get client help and concluded that client should 'be bold' and ask family members for help. Review of a RN Coordination record of 1/17/2021 for Client #6 documented that client's home was 'cluttered, filled with boxes' with recommendation that client get help getting her home in order, be bold to ask family members for help. No notification to physician on clients needs for assistance was documented. Review of the coordination note between RN and LPN revealed pain was not discussed or addressed but rather both staff discussed client's environmental concerns and indicated that Client #6 had been 'weepy on last 2 visits'. No communication to physician. Review of visit note record of 1/20/2021 for Client #6 indicated her pain score was 4 out of 10, but on being asked about her sense of peace and feeling loved she declined to answer. Review of visit record for 1/27/202, client's pain level is up again with her scoring her pain level as 6 out of 10 with pain occurring all the time, but still no communication made to physician on client's ongoing pain levels. In an interview on 2/16/2021 at 11:00AM with the Clinical Manager, she was asked, what the facility had done to address Client#6 pain needs, and emotional expressions of distress, along with client's inability to care for her home, Clinical Manager stated they did not have a social worker since October 2020, so no referrals could be done." When asked what were they doing to ensure client's psychosocial needs could be met, she said, "we do not have a social worker, what can we do." She was asked why did it take so long to address so long to address Client#6 pain, she stated she did not know. When asked why was the physician not informed that client may need assistance within her home and perhaps need a home health aide. She stated the facility only had 1 home health aide and most times client's refuse home health aide services. She was asked if Client #6 had been offered such services. She stated she did not know. 2. Client #7 is a 51-year-old with a complex medical history that included a recent diagnosis in January 2020 of cervical and breast Ca for which client had chemotherapy and radiation which left her feeling very weak. Following this Client had a hip replacement in April 2020 with subsequent right hip prosthetic that became infected, so she was placed on a wound vac on December 29th, 2020 and referred for home health services for skilled nursing on 1/5/2021. Client #7 visit note record on 1/6/2021 revealed that client was assessed for pain and indicated that her level of pain was a 6 out of 10. She reported that her pain occurred both during the day and the night. The assessment also indicated that client was easily fatigued and there was need for conservation training, but physician was not contacted because client had "just had it" as she had transferred from another agency (clinician documented). Assessment note described client as 'depressed' and indicated that she had problems with her support system and that they were unavailable and unable to help care for client. In the narrative clinician indicated that client had to change home health agencies because of insurance changes, and had all therapies with previous agency, lived in a mobile home with 4 steps to go into her living room and client was frustrated and depressed, and often will not eat more than one meal a day. There was no information that physician was alerted to client's condition and need for Psychosocial assessment. Care continued, but it does not document client's psychosocial state, but Client#7 had a hospitalization on 1/20/2021for aspiration Pneumonia, along with Sepsis and returned to home, care on 1/26/2021. On the visit note record for 1/26/2021, Clinician continues to describe client as 'depressed, edema of 4+, impaired mobility, pain score of 10'. In the narrative clinician documented, client is 'feeling frustration, husband does not help much, home is cluttered and client cries easily.' There is no indication physician is notified of client's psychosocial distress or level of pain. The visit record of 1/27/202 documented client saying, 'pain is bad', scoring it a 10 out of 10 on the pain scale but there is no indication that this information was conveyed to the physician so that a pain medication review could be conducted . Client#7 continued to be assessed as 'anxious and depressed with no sense of peace 'in her life. In the narrative clinician documented resident has difficulty using steps in her home but still none of this information is communicated to the physician. The visit record of 1/28/2021 for Client#7 continued to report pain during the day and night as 8 out of 10 on the pain scale. Client #7 continued to be assessed as ' anxious and depressed' but no psychiatric assessment was done, for physician was not informed. Clinician in her narrative note recorded that she spoke to doctor about client's wound which was oozing profusely, reported client's edema but Clinician makes no report of client's pain or mental state to physician. The visit record of 2/5/2021. Client coordination note finally indicated contact with physician who stated he will follow up with client's PCP about clients pain medication management. During an interview with Clinical Manager on 2/16/2021 at 11 AM, she was asked about addressing client's pain. She stated their 'doctors are quite funny about pain management'. 3. Client #13 is a 90 year old man who lives with his 90 year old wife, and who was previously independent with all his activities of daily living, but who had a recent cerebral infarct along with cellulitis of his upper right limb, for which he was referred to Home Health services on 1/24/2021, for SN, PT, OT for management of his pain, health teaching, mobility and fall prevention. Client's physician orders at admission on 1/24/2021 does not document any prescribed pain medication. Client#13 visit note record on 1/25/2021 documented client's pain as a 5 out of 10 that was constant night and day. Therapist in his narrative note indicated client had muscle spasms in neck that exacerbate pain in client's shoulder and arm and indicated patient's goal was to be without pain, indicated physician office was contacted but it was closed. Visit note report of 1/28/2021 indicated an increase in client's pain to a 6 out of 10. Visit record for 1/30/2021 recorded client's pain score as 5 out of 10 and in the narrative record indicated client was using lidocaine patch and ice daily to try to manage pain but there was no documentation that physician was notified of client's ongoing pain. Visit record of 2/1/202. Client reported his pain as 6 out of 10 continuous but still no communication with physician. Visit record of 2/2/202 recorded pain level of client as 6 out of 10 continuous. All disciplines RN, PT, COTA continued to document continuous pain, day and night with score of 6 out of 10 on 2/4/2021, 2/5/2021 but no communication with physician done. Client's pain increased with a recording in the visit note record of 2/12/2021 to a score of 7 out of 10 on the pain scale, Clinician recorded client was 'grimacing, frowning, guarding' finally it says physician was contacted. In an interview with the Therapy Coordinator on 2/17/2021 at 1:18 PM, asked about therapy recording of pain and what they should do. Stated Normally if pain is observed or told to the therapy team , or if there is significant change in pain then therapy team are supposed to notify the physician, nurse, also inquire from the patient about any pain relieving medication, and educate on non-narcotic recommendations. Reported that Client #13 had an appointment to see the neurologist for his hand pain next week, asked why did it take so long for pain to be addressed. The Therapy Coordinator stated she did not know; that might be a nursing question. In an interview on 2/17/2021 at 1:43 PM with the Clinical Coordinator, she was asked to describe how pain should be managed or addressed by clinicians, she stated staff would assess pain, check if they have over the counter medication, check and educate on nonpharmacological means to address pain. If they are still experiencing pain it may appear that whatever they are having is not working, so staff should contact physician and explore alternatives. Review of facility Policy and procedure #HH037 titled Pain Management and end of life care stated ' comprehensive pain assessment is conducted on each patient on admission. when pain has been identified the clinician will reassess the patient's pain level on every visit ... and when pain is identified will provide treatment as ordered or will refer to the physician for treatment'. 4, Record review for Patient # 16 revealed 92 year old female with Start of Care (SOC) 2/3/21. Her diagnosis: Rhabdomyolysis, malignant neoplasm of bone, hypertension and multiple abrasions to left lower leg, right thigh, right elbow and left forearm. The Plan of Care (POC) included: Skilled Nurse (SN) 2 wk 2, 3 wk 1, 2 wk 2. Wound care to multiple skin tears as result of fall every 2 days. Physical Therapy (PT) 1 wk 1, 2 wk 4. Review of the initial SN assessment dated 2/3/21 revealed she had a pain level of 6 to the lumbar spine and between 3-4 related to the multiple large skin tears. Review of the medication profile found no order for pain medication. On 2/8/21, per the SN assessment found pain level was indicated as 3 to the right and left lower legs skin tears. On 2/11/2, the physical therapist documented in his assessment that Patient # 6 had pain level of 9 to thoracic spine. (1 lest amount of pain with 10 the highest). There was no documentation the physician was notified of the increased pain. There were no communication notes found that the Registered Nurse Case Manager was notified to assess for need of pain medication. .

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: Based on record review and staff interview, the facility failed to adequately communicate client's changing needs in the areas of pain management, psychosocial needs to the physician for possible reassessment and referral for additional services for 3 clients (#6 ,7, 13) out of a sample of 20. Facility failed to have available a Social worker to provide services directly or under arrangement to assess clients psychosocial needs for 2 clients (#6, 7) out of a sample of 20. Findings include: 1. Client #6 is a 71-year-old who was diagnosed with severe venous insufficiency with a deep non-pressure chronic ulcer of the left ankle that had the fat layer exposed. She also had cellulitis in the left lower limb and was experiencing pain. She was also morbidly obese which made it very difficult to ambulate and perform her activities of daily living. Client #6 had a fall at home where she scraped the leg and was referred for home health services on 1/7/2021, for skilled nursing services for medication management, wound care , assessment, and review of effectiveness of pain management. Review of client's medication orders at the time of her admission to home health services revealed Client #6 had no pain medication ordered. Review of the comprehensive assessment done on 1/7/2021 revealed that client indicated that her activities including her ability to leave home was restricted due to her pain. She indicated that she was experiencing pain in her neck and lumbar region. She revealed that on a numeric scale of 0 no pain and 10 most pain her scoring of pain she experienced was a 5. Client #6 also indicated feelings of depression and sense of hopelessness over several days. It was documented in the narrative note, "please assess living situation on future visit" but facility had no Social worker to perform psychosocial assessment. Review of visit note record on 1/11/2021 revealed that Client #6 pain had increased and was now scored on the numeric scale as a 7. The narrative note indicated client's house 'was cluttered, crowded and she was advised on removing clutter.' There was no indication in the record that physician was contacted on client's need for additional services like home health aide to aid client to remove clutter, or need for social services referral to assess social environment and support for client. Client's pain had increased from 5 to a score of 7, but this was not communicated to the physician so that client's pain could be addressed. Review of visit note record on 1/13/2021 client expressed her pain level as a 7 out of 10 ,the narrative documented pain level and wound care, but again no communication with physician to attempt to gain pain relieving medication for Client #6. Review of visit note of 1/15/2021 revealed Client#6 pain level was a 6 out of 10 and documented client as feeling "down, discouraged and weepy." In the coordination section of the visit note for 1/15/2021 the clinician indicated that she communicated to the Registered Nurse (RN) but no communication was made to the physician. The narrative note indicated client 'felt alone, weepy', discussed options to get client help and concluded that client should 'be bold' and ask family members for help. Review of a RN Coordination record of 1/17/2021 for Client #6 documented that client's home was 'cluttered , filled with boxes 'with recommendation that client ' get help getting her home in order, be bold to ask family members for help.' No notification to physician on client's needs for assistance was documented. Review of the coordination note between RN and LPN revealed pain was not discussed or addressed but rather both staff discussed client's environmental concerns and indicated that Client #6 had been 'weepy on last 2 visits'. No communication to physician. Review of visit note record of 1/20/2021 for Client #6 indicated her pain score was 4 out of 10, but on being asked about her sense of peace and feeling loved she declined to answer. Review of visit record for 1/27/2021 client's pain level is up again with her scoring her pain level as 6 out of 10 with pain occurring all the time, but still no communication made to physician on client's ongoing pain levels. Review of visit note record of 1/29/2021 indicated Client #6 continued to have elevated pain levels scoring her pain as a 7 out of 10, now client has received a medication script order for Gabapentin for her pain, which had not yet been filled. There is no indication in the record that any assessment was done to determine if client needed help to collect her pain medication. Next visit note record of 2/5/2021, documented that Client #6 after having her pain medication reported no pain. In an interview on 2/16/2021 at 11 AM with the Clinical Manager, she was asked what the facility had done to address Client #6 pain needs, and emotional expressions of distress, along with client's inability to care for her home. The Clinical Manager stated they "did not have a social worker since October 2020, so no referrals could be done." When asked what were they doing to ensure client's psychosocial needs could be met said, "we do not have a social worker, what can we do?" Asked why it had taken so long to address Client #6 pain, stated she 'did not know'. When asked why physician was not informed that client may need assistance within her home and perhaps a home health aide, stated the facility only had 1 home health aide and most times clients refuse home health aide services. When asked if Client #6 had been offered such services, stated did not know. Clinical Manager attested that lack of a social worker meant that all of clients needs could not be met. 2. Client #7 is a 51-year-old with a complex medical history that included a recent diagnosis in January 2020 of cervical and breast Ca for which client had chemotherapy and radiation which left her feeling very weak. Following this Client had a hip replacement in April 2020 with subsequent right hip prosthetic that became infected, so she was placed on a wound vac on December 29th, 2020 and referred for home health services for skilled nursing on 1/5/2021. Client #7 visit note record on 1/6/2021 revealed that client was assessed for pain and indicated that her level of pain was a 6 out of 10. Reported that her pain occurred both during the day and the night. The assessment also indicated that client was easily fatigued and there was need for conservation training, but physician was not contacted because client had "just had it" as she had transferred from another agency. (clinician documented). Assessment note described client as 'depressed' and indicated that she had problems with her support system and that they were unavailable and unable to help care for client. In the narrative, clinician indicated that client had to ' change home health agencies because of insurance changes, and had all therapies with previous agency, lived in a mobile home with 4 steps to go into her living room and client was frustrated and depressed, and often will not eat more than one meal a day'. There was no information that physician alerted to client's condition and need for Psychosocial assessment. Care continued, but it does not document client's psychosocial state, but Client#7 had a hospitalization on 1/20/2021 for aspiration Pneumonia, along with Sepsis and returned to home care on 1/26/2021. On the visit note record for 1/26/2021, Clinician continues to describe client as 'depressed, edema of 4+, impaired mobility, pain score of 10'. In the narrative clinician documented client is 'feeling frustration, husband does not help much, home is cluttered and client cries easily.' There is no indication physician was notified of client's psychosocial distress or level of pain. The visit record of 1/27/2021 documented client saying 'pain is bad', scoring it a 10 out of 10 on the pain scale but there was no indication that this information was conveyed to the physician so that a pain medication review could be conducted . Client #7 continued to be assessed as 'anxious and depressed with no sense of peace 'in her life. In the narrative clinician documented resident has difficulty using steps in her home but still none of this information is communicated to the physician. The visit record of 1/28/2021 for Client#7 continues to report pain during the day and night as 8 out of 10 on the pain scale. Client #7 continued to be assessed as ' anxious and depressed' but no psychiatric assessment was done. Clinician in her narrative note recorded that she spoke to Doctor about clients wound which was oozing profusely, reported client's edema but Clinician made no report of client's pain or mental state. The visit record of 2/5/2021 Client coordination note finally indicated contact with physician who stated he will follow up with client's PCP about client's pain medication management. During an interview with Clinical Manager on 2/16/2021 at 11 AM, she was asked about addressing client's pain. She stated their 'Doctors were quite funny about pain management." She again attested that a lack of social worker meant that clients needs in that area may fall through the cracks, but they had been advertising for the longest while to get a Social Worker. 3. Client #13 is a 90 year old man who lives with his 90 year old wife, and who was previously independent with all his activities of daily living, but who had a recent cerebral infarct along with cellulitis of his upper right limb, for which he was referred to Home Health services on 1/24/2021, for SN, PT, OT for management of his pain, health teaching, mobility and fall prevention. Client physician orders at admission on 1/24/2021 did not document any prescribed pain medication. Client#13 visit note record on 1/25/2021 documented client's pain as a 5 out of 10 that was constant night and day. Therapist in his narrative note indicated client had muscle spasms in neck that exacerbated pain in client's shoulder and arm and indicated patient's goal was to be without pain. Indicated physician's office was contacted but it was closed. Client coordination note of 1/27/2021 revealed a fax to physician informing him on client's pain and requesting a mobile X-ray which the physician responded that request was approved but review of client's record revealed this X-ray was never performed. . Visit record for 1/26/2021 indicated client scored his pain as 5 out of 10, but documented that no coordination or follow up was done, just documenting that client had a lidocaine patch which was not recorded on client's medication record. Visit note report of 1/28/2021 indicated an increase in client's pain to a 6 out of 10, also recorded that medication record was not updated because there were no changes, but medication record still did not contain client's lidocaine patch. Visit record for 1/30/2021 recorded client's pain score as 5 out of 10 and in the narrative record indicated client was using lidocaine patch and ice daily to try to manage pain but there was no documentation that physician was notified of client's ongoing pain. Visit record of 2/1/202. Client reported his pain as 6 out of 10 continuous but still no communication with physician. Visit record of 2/2/2021. Reported pain level of client as 6 out of 10 continuous . All disciplines RN, PT, COTA continued to document continuous pain, day and night with score of 6 out of 10 on 2/4/2021, 2/5/2021. Client's pain increased with a recording in the visit note record of 2/12/2021 to a score of 7 out of 10 on the pain scale , Clinician recorded client was 'grimacing, frowning, guarding' finally it says physician was contacted. In an interview with Therapy Coordinator on 2/17/2021 at 1:18 PM. She was asked about therapy recording of pain and what therapists should do. She stated normally if pain was observed or told to the therapy team, or if there was significant change in pain, then therapy team were supposed to notify the physician , nurse; also enquire from the patient about any pain relieving medication, and educate on non-narcotic recommendations. Reported that Client #13 had an appointment to see the neurologist for his hand pain next week , asked why did it take so long for pain to be addressed. Stated did not know; that might be a nursing question. In an interview on 2/17/2021 at 1:43 PM with the Clinical Coordinator for nursing, she was asked how often medication reconciliation was done. Stated medication reconciliation was supposed to be done at each visit. Went on to say that staff were supposed to add new orders, add or discontinue medication that they have seen. They should be looking at all the bottles in the home or packs. She was asked if staff had at any time documented in the medication records; that client was using a Lidocaine patch. Attested that Lidocaine patch was observed on client and her review revealed it was documented in the notes but was absent from Client's medication profile. Clinical Coordinator was asked to describe how pain should be managed or addressed by clinicians. She stated staff would assess pain, check if they have over the counter medication, check and educate on nonpharmacological means to address pain. If they were still experiencing pain, it may appear that whatever they were having was not working, so they should contact physician and explore alternatives. Stated would ask questions to try to identify the source of pain. She was then asked if there was a request by staff for possible X-ray to identify possible source of pain had been done for Client #13, stated no. Stated they all have to bear the responsibility for that, for the physician approved staff request to have an X-ray but it was not done. The Clinnical Coordinator stated the expectation was after the physician said X-ray request was approved that it should have been followed up to ensure the order was received and carried out. Stated it was all disciplines responsibility to have ensured that pain was addressed and that the follow up to the x ray request was done. Attested for Client #13 that this was not done by any of the disciplines. Review of facility Policy and procedure #HH037 titled Pain Management and end of life care stated ' comprehensive pain assessment is conducted on each patient on admission. when pain has been identified the clinician will reassess the patient's pain level on every visit ... and when pain is identified will provide treatment as ordered or will refer to the physician for treatment.' Review of Facility policy titled Providing Care Treatment and Services Policy Number HH035 last revised 8/2020 Part C (1) documented "The agency will provide care treatment and services in a collaborative manner. Part C(3) The agency will notify the physicians of changes patient's condition or responses to care in a timely basis". Page 6(13) Policy #HH035 "The agency will provide Medical Social Services by or under supervision of a qualified Medical Social Worker". 13(a) iv Medical Social services assisting the physician and other members of the health team in understanding the significant social and emotional factors related to the patient's health problems. (v) Assessing the social and emotional factors in order to estimate patient's capacity and potential to cope with the problems of daily living. (vi)provide services planned to restore the patient to optimum social and health adjustment within this capacity.(viii)Utilizing resources such as family and community agencies to assist the patient to resume life in the community or learn to live with his disability. .