Every finding on record at Alden Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #43979, RN, Health Facilities Evaluator Nurse Surveyor ID #43929, RN, Health Facilities Evaluator Nurse Unduplicated Admission: 116 Active Patients: 14 Sample Size: 7 Home Visits: 3

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Facility failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) had Federal and State funded entities information. This failure had the potential to prevent patients be familiar with the services that are available to them. Findings: A review of Patient 1’s “Patient Information” indicated the patient's start of care (SOC) of 10/24/2022, and a primary diagnosis of early onset cerebellar ataxia (involuntary movements). A review of Patient 2’s “Patient Information” indicated a start of care (SOC) date of 6/27/2022 and a primary diagnosis of Type 2 Diabetes (high blood sugar). A review of Patient 3’s “Patient Information” indicated a start of care of 11/3/2022, diagnosis section has been left blank. A review of Patient 4’s profile indicated a start of care date (SOC) of 8/6/22, with diagnoses including autonomic dysreflexia (an abnormal, overreaction of the involuntary nervous system to stimulation, resulting in increased heart rate, excessive sweating, high blood pressure). A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) A review of Patient 6’s profile indicated a start of care date (SOC) of 3/16/22, with diagnoses including pressure ulcer of left buttock, stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful.) A review of Patient 7’s profile indicated a start of care date (SOC) of 12/15/21, with diagnoses including encounter for surgical after following surgery on the circulatory system. A record review of agency’s admission packet/folder on 11/15/2022, at 9 a.m., indicated there was no listing or contact information for Federal or State funded agencies. During an interview on 11/15/2022, at 9:40 a.m., with the Administrator (ADM), the ADM stated, “What we do is refer them (patients) to social worker, for discharge planning. We send our social worker to give them information for placement/planning. We used to have a full list of everything, but we don’t any longer. The social worker gives them all that information.” ADM stated that if the patient did not have an assigned social worker, “On initial assessment if we see the need we supply that information. If we don’t see the need we don’t supply, it on a regular basis.”

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure the comprehensive assessment is completed in a timely manner, no later than 5 calendar days after the start of care for one of seven sampled patients (Patient 3). This deficient practice resulted in the delay of identifying the patients’ care needs. Findings: A review of Patient 3’s “Patient Information” indicated a start of care of 11/3/2022, diagnosis section had been left blank. Patient 3's initial assessment (OASIS: Outcome and Assessment Information Set - a standardized data set that measures quality and outcomes. It contains information regarding the patient such as the clinical condition, comorbidities, physical and mental state, functional status, living situation and health care needs.), plan of care (POC), medication profile, and physical therapist/nursing notes were requested, none were provided. Patient 3’s face sheet was provided; primary diagnosis section had been left blank. A concurrent interview and record review on 11/14/2022, at 2:40 p.m., with Administrator (ADM) of Patient 3’s Electronic Medical Record (EMR) indicated there was no initial OASIS or POC documented. During a concurrent interview with the ADM stated, “I don’t see anything, whether they were in contact with patient. I have to call them to find out what happened.” ADM stated she notified the admitting nurse about the initial assessment (OASIS) not being documented and that the admitting nurse was documenting “right now”. During an interview on 11/14/2022, at 2 p.m., with Administrator (ADM), ADM stated, “The complete assessment, I am giving them two weeks to complete, because it’s long. The OASIS should be done in five days, but we give them two weeks to complete. The initial OASIS assessment should be completed within five days and documented within 14 days.” A review of the agency’s policy and procedure titled, “Coordination of Services”, dated 7/2020, indicated “The comprehensive assessment/OASIS assessment is not required to be completed at the initial visit but no later than five calendar days after the start of care.” A review of the agency’s policy and procedure titled, “Initial Assessment Visit and Comprehensive Assessment”, dated 7/2008, indicated “The initial assessment visit is completed within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date.” A review of the agency’s policy and procedure titled, “OASIS Assessment”, dated 5/2017, indicated “The Case Manager: b. Documents the initial assessment on the Nursing Assessment form. c. Begins the patient Plan of Care based on the assessment data obtained in the initial visit”. A review of the agency’s policy and procedure titled, “Skilled Nursing Services” dated 2/02, indicated “Registered Nurse duties include…: c. Develop and initiate the Plan of Care… e. Assign, supervise… j. Prepare timely clinical and progress notes… License Vocational Nurse duties include… d. Prepare timely clinical notes…” A review of the agency’s policy and procedure titled, “Clinical Record”, dated 7/2008, indicated “1. The clinical record includes the following: a. Admission record. d. Plan of Care. n. Clinical notes by all multidisciplinary members. 2. Clinical records are: a. Kept current and in detail to identify the patient’s health status for health care providers.”

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 observation, interview, and record review the Home Health Agency failed to review and document all the medications the patient is currently using for four of seven sampled patients (Patient 1, Patient 3, Patient 4, and Patient 5). This deficient practice placed patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. Findings: A review of Patient 1’s “Patient Information” indicated a start of care (SOC) of 10/24/2022, and a primary diagnosis of early onset cerebellar ataxia (involuntary movements). During a joint home visit on 11/15/2022, at 3 p.m., with ADM at Patient 1’s home, ADM failed to reconcile the patient's medication. ADM stated, “If there was skilled nurse involved in the case, then she reconciles the medications every visit.” A review of Patient 3’s “Patient Information” indicated a start of care of 11/3/2022, diagnosis section has been left blank. A concurrent interview and record review on 11/14/2022, at 2:40 p.m., with Administrator (ADM) of Patient 3’s Electronic Medical Record (EMR) indicated there was no Medication profile documented. ADM stated, “I don’t see anything, whether they were in contact with patient. I have to call them to find out what happened.” During an interview on 11/15/2022, at 9:40 a.m., with ADM, ADM stated, “When the nurse visits the patient we generate a medication list for the patient, a medication profile.” A review of Patient 4’s profile indicated a start of care date (SOC) of 8/6/22, with diagnoses including autonomic dysreflexia (an abnormal, overreaction of the involuntary nervous system to stimulation, resulting in increased heart rate, excessive sweating, high blood pressure). During a home visit on 11/15/22, at 9:10 a.m., the ADM asked Patient 4 if she was taking new medications. Patient 4 replied “No” and the ADM did not review the medications present at the patient’s home. The medication profile was not observed at the patient’s home and was not observed being used by the ADM. During an interview on 11/16/22, at 10:15 a.m., the ADM stated during the home visit on 11/15/22, she did not review the medications Patient 4 was taking. A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) During a home visit on 11/15/22, at 10:10 a.m., nursing care was observed being performed by Licensed Vocational Nurse 1 (LVN1). LVN 1 did not review the medications Patient 5 was taking during the home visit. During an interview on 11/16/22, at 10:15 a.m., the ADM stated medications are supposed to be reviewed every visit. The ADM stated the process of reviewing medications was as follows: the nurse is supposed to bring the list of medications the agency prints as soon as it is updated; the nurse is supposed to review the medication bottles the patient has at home and review line by line the name of the medication, dose, frequency and route; the nurse reviews the information obtained and compare it to the medication list. A review of the agency’s policy and procedure titled, “Medication Policy”, dated 3/2020, indicated “During initial evaluation visit, the Registered Nurse evaluates every medication that the patient takes and documents them in the Medication Profile.”

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to update the comprehensive assessment for one of seven sampled patients (Patient 2) within the required time frame. This deficient practice has the potential to result in the patients receiving services they did not need. Findings: A review of Patient 2’s “Patient Information” indicated a start of care (SOC) date of 6/27/2022 and a primary diagnosis of Type 2 Diabetes (high blood sugar). During a record review on 11/15/2022, at 10:30 a.m., of Patient 2’s electronic medical record (EMR), Patient 2’s recertification OASIS (Outcome and Assessment Information Set - a standardized data set that measures quality and outcomes. It contains information regarding the patient such as the clinical condition, comorbidities, physical and mental state, functional status, living situation and health care needs) disclosed the OASIS was dated 10/24/2022 was documented on 11/2/2022. During an interview on 11/15/2022 at 1:35 p.m. with the Administrator (ADM), the ADM stated that the rectification nurse visit, “should be scheduled and done within the last 5 days of the previous certification.” ADM stated that they monitor patients progress verbally. ADM stated, “They give us verbal report, there is a case conference. We try to do case conference at least a month. Even though we don’t document it, the report is given to the LVN to follow up. We are not documenting the verbal report. That is something that we have to look at what others are doing. It’s not documented.” A review of agency’s policy and procedure titled, “Skilled Nursing Services” dated 2/02, indicated “Registered Nurse duties include…: c. Develop and initiate the Plan of Care… e. Assign, supervise… j. Prepare timely clinical and progress notes… License Vocational Nurse duties include… d. Prepare timely clinical notes…”

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: Based interview and record review the Home Health Agency (HHA) failed to ensure a Plan of Care (POC) was reviewed and signed by a physician for one of seven sampled patients (Patient 4). This deficient practice has the potential to result in the physician not being aware of the services being provided to the patient by the HHA. A review of Patient 4’s (P4) profile indicated a start of care date (SOC) of 8/6/22, with diagnoses including autonomic dysreflexia (an abnormal, overreaction of the involuntary nervous system to stimulation, resulting in increased heart rate, excessive sweating, high blood pressure). A review of P4’s medical record titled, “Plan of Care”, for certification period 10/5/22-12/3/22, did not indicate a doctor’s signature. During an interview on 11/15/22, at 1:55 p.m., the ADM stated the POC needed to be signed by the doctor within 30 days of the beginning of the certification period. During an interview on 11/15/22, at 2:25 p.m., the ADM stated P4’s POC was not signed by the doctor. A review of agency’s policy and procedure titled, “Plan of Care (Form CMS 485)”, dated 7/2011, indicated “Home Health services are furnished to a patient under the supervision of a physician who establishes and reviews the Plan of Care… 1. The Plan of Care is: a. Developed in collaboration with Agency personnel… b. Approved and signed by the physician within 30 working days from the date of patient admission…” A review of the agency’s policy and procedure titled, “Coordination of Services”, dated 7/2020, indicated, “Procedure…Plan of Care…3. The Plan of Care is mailed to the physician with instructions to review, sign and return within 30 working days.”.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to include information required in the plan of care for one of seven sampled patients (Patient 3). This failure had the potential to result in patient’s not receiving appropriate healthcare services that could affect their quality of life and not knowing what, when, and by whom services were expected. Findings: A review of Patient 3’s “Patient Information” indicated a start of care of 11/3/2022, diagnosis section has been left blank. Patient 3’s initial assessment (OASIS: Outcome and Assessment Information Set - a standardized data set that measures quality and outcomes. It contains information regarding the patient such as the clinical condition, comorbidities, physical and mental state, functional status, living situation and health care needs.), plan of care (POC), medication profile, and physical therapist/nursing notes were requested, none were provided. Patient3’s face sheet was provided; primary diagnosis section has been left blank. A concurrent interview and record review on 11/14/2022, at 2:40 p.m., with Administrator (ADM) of Patient3’s Electronic Medical Record (EMR) indicated there was no initial OASIS or POC documented. ADM stated, “I don’t see anything, whether they were in contact with patient. I have to call them to find out what happened.” During an interview on 11/14/2022, at 2 p.m., with Administrator (ADM), ADM stated that patients plan of care was driven by the OASIS. A review of the agency’s policy and procedure titled, “Coordination of Services”, dated 7/2020, indicated “The comprehensive assessment/OASIS assessment is not required to be completed at the initial visit but no later than five calendar days after the start of care.” A review of the agency’s policy and procedure titled, “Initial Assessment Visit and Comprehensive Assessment”, dated 7/2008, indicated “The initial assessment visit is completed within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date.” A review of the agency’s policy and procedure titled, “Skilled Nursing Services” dated 2/02, indicated “Registered Nurse duties include…: c. Develop and initiate the Plan of Care…” A review of the agency’s policy and procedure titled, “OASIS Assessment”, dated 5/2017, indicated “The Case Manager: b. Documents the initial assessment on the Nursing Assessment form. c. Begins the patient Plan of Care based on the assessment data obtained in the initial visit”. A review of the agency’s policy and procedure titled, “Clinical Record”, dated 7/2008, indicated “1. The clinical record includes the following: a. Admission record. d. Plan of Care. 2. Clinical records are: a. Kept current and in detail to identify the patient’s health status for health care providers.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure written instructions regarding the patient’s care was provided for three of seven sampled patients (Patient 1, Patient 4, and Patient 5). This deficient practice placed these patients at risk of not fully understand what services to expect from the HHA, the purpose of each service and when to expect the services. Findings: A review of Patient 1’s “Patient Information” indicated a start of care (SOC) of 10/24/2022, and a primary diagnosis of early onset cerebellar ataxia (involuntary movements). During a joint home visit on 11/15/2022, at 3 p.m. with the administrator (ADM) at Patient1’s home, ADM stated it was not their practice to provide a copy of patients plan of care (POC). ADM stated, “We discuss the POC with the patient and the family at the SOC, we update verbally. We don’t bring it with us.” A review of Patient 4’s profile indicated a start of care date (SOC) of 8/6/22, with diagnoses including autonomic dysreflexia (an abnormal, overreaction of the involuntary nervous system to stimulation, resulting in increased heart rate, excessive sweating, high blood pressure). During a home visit on 11/15/22, at 9:30 a.m., with the ADM, the agency’s folder at Patient 4’s home was reviewed. The POC was not included in the folder. During an interview on 11/15/22, at 9:30 a.m., the ADM stated the agency does not issue the patients the written plans of care. A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) During an interview at the home visit on 11/15/22, at 10:10 a.m., Caregiver 1 (CG 1) stated “the bath nurse comes once a week.” Licensed Vocational Nurse 1 (LVN 1) “nurse comes twice a week”. During a concurrent observation and interview at the home visit on 11/15/22, at 10:30 a.m., contents of the patient folder was reviewed. No POC was observed. LVN 1 stated verbal communication regarding services provided were discussed with the patients, and “we don’t give them anything in writing.” LVN 1 stated CG 1 was confused about her visit frequency because the home health aide comes twice a week, and she comes once a week. LVN 1 stated “It would help if she had something in writing, so she doesn’t get confused.” A review of the agency’s policy and procedure titled, “Plan of Care”, dated 7/11, did not indicate a process for providing the patient written information regarding the plan of care.

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 interview and record review the Home Health Agency failed to perform supervisory visits for two of seven sampled patients (Patient 2 and Patient 5) provided License Vocational Nurse (LVN) services. This deficient practice has the potential to result in the patient's identified needs or progress will not be evaluated for further provision of LVN services. Findings: A review of Patient 2’s “Patient Information” indicated start of care (SOC) date of 6/27/2022 and a primary diagnosis of Type 2 Diabetes (high blood sugar). During a concurrent interview and record review on 11/15/2022 at 1:35 p.m. with the Administrator (ADM) of Patient 2’s Electronic Medical Record (EMR) indicated the SOC was on 6/27/2022. ADM stated that the License Vocational Nurse (LVN) supervisory visits should be conducted monthly. ADM stated that there were two supervisory visit notes in Patient 2’s conducted on 8/25/2022 and 10/24/2022. ADM stated that the supervisory visits are important, “To keep track of patient, what’s going on with the patient. Satisfaction, providing a good service.” A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) During an interview on 11/15/22, at 1:45 p.m., the ADM stated it was important to do a joint supervisory visit with the LVN to make sure "everything was okay, see how they work and adhere to infection control processes". During an interview on 11/15/22, at 2:08 p.m., the ADM stated there was no documentation of LVN supervisory visits for Patient 5 for the certification period 9/24/22-11/22/22. A review of Patient 5’s medical record titled, “Plan of Care”, for certification period 9/24/22-11/22/22, indicated, “…Skilled Nurse: 1wk9 (1 visit per week for 9 weeks) for skilled observation and assessment of overall status…”. Further review of the record did not indicate LVN supervisory visits. A review of the agency’s policy and procedure titled, “Supervisory Visits of Home Health Aides and Licensed Vocational Nurses”, dated 2/2015, indicated, “Policy A Registered Nurse conducts supervisory visits of LVN’s at least monthly…the Supervisory visits must be documented in the patient’s clinical record.” A review of the agency’s policy and procedure titled, “Skilled Nursing Services” dated 2/02, indicated “Registered Nurse duties include… e. Assign, supervise and teach other nursing personnel within their scope of practice;”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure a care plan was created for the Home Health Aide (HHA) when providing services to one of seven sampled patients (Patient 5) provided HHA services. This deficient has the potential to result in the HHA providing care without adhering to a care plan. Findings: A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) During an interview on 11/15/22, at 1:50 p.m., the administrator (ADM) stated Patient 5 did not have a care plan and should have had a written care plan for the HHA providing services. The ADM stated a care plan was important to the staff know what services to provide and which services to evaluate. When asked, how do you know which services you are evaluation if there is no HHA care plan? The ADM stated, “you are right, if it's not documented, it wasn’t done.” A review of Patient 5’s medical record did not indicate a care plan was developed for the HHA. A review of the agency’s policy and procedure titled, “Coordination of Services”, dated 7/2020, indicated, “Procedure referrals/initial evaluation…10. The Case Manager develops a Home Health Aide Assignment for those patients who will benefit from Home Health Aide services. The Home Health Aide assignment sheet will contain the parameters to be reported to the RN or Nursing Supervisor by the Home Health Aide.” A review of the agency’s policy and procedures titled, “Certified Home Health Aide Services”, dated 7/05, indicated, “Policy…The Case Manager shall provide written instructions of duties the Aide is to perform in the Home Health Aide Assignment… The Home Health Aide services shall be in accordance with the Home Health Aide Assignment and shall be supervised by qualified clinical personnel…”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency failed to perform supervisory visits for Home Health Aide (HHA) services for one of seven sampled patients (Patient 5). This deficient practice resulted in the HHA not be evaluated for patient care and services. Findings: A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) During an interview on 11/15/22, at 1:45 p.m., the administrator (ADM) stated supervisory visits for the HHA should occur every 14 days. The ADM stated supervisory visits were important to ensure patients are satisfied with the services being provided and to monitor the relationship between the patient and the nurse. During an interview on 11/15/22, at 1:50 p.m., the ADM stated there was no supervisory visits for the HHA. A review of Patient 5’s medical record did not indicate supervisory visits for the HHA. A review of the agency’s policy and procedure titled, “Supervisory Visits of Home Health Aides and Licensed Vocational Nurses”, dated 2/2015, indicated, “Policy A Registered Nurse performs a supervisory visit of each CHHA at the patient’s place of residence at least every two weeks…the Supervisory visits must be documented in the patient’s clinical record.” A review of the agency’s policy and procedure titled, “Skilled Nursing Services” dated 2/02, indicated “Registered Nurse duties include… e. Assign, supervise and teach other nursing personnel within their scope of practice;”

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency failed to ensure an annual observation and evaluation of the Home Health Aide (HHA) skills was conducted for one of seven sampled patients (Patient 5). This deficient practice resulted in the home health agency not having federally mandated oversight of the services provided by the HHA. Findings: A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) A review of Patient 5’s medical record titled, “Physician order”, dated 11/1/22, indicated “Certified Home Health Aide (HHA) 1wk3 (one a week for three weeks) to assist with safe bathing activities and personal care.” During an interview on 11/16/22, at 9:50 a.m., the administrator (ADM) stated HHA 1’s onsite direct supervision in the home setting was done 7/1/2020. The ADM stated she had not done an onsite direct supervision for 2021. The ADM stated onsite direct supervision of the HHA in the home setting was important to review and assess how they are taking care of the patient, their interaction with the patient, and ensuring they are following the plan of care. A review of the agency’s policy and procedure titled, “Competency Evaluation Program for Certified Home Health Aide”, dated 2/2002, indicated, “Policy…Three months prior to each Home Health Aides annual evaluation, the Clinical Supervisor or designee shall oversee the Aide’s patient care skills, using the Competency Evaluation Skills Checklist.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure staff documented and uploaded their current clinical notes in a timely manner for four of seven sampled patients (Patient 1, Patient 2, Patient 3, and Patient 5). This deficient practice had the potential to result in patient care records not being validated for the care received and the inability to know which care provider furnished the prescribed care/services. Findings: A review of Patient 1’s “Patient Information” indicated a start of care (SOC) of 10/24/2022, and a primary diagnosis of early onset cerebellar ataxia (involuntary movements). Patient 1’s Occupational and Physical Therapist notes were requested on 11/14/2022. Physical therapist notes for 10/31/2022 were the only notes provided. During a record review on 11/15/2022 at 12:40 p.m. of Patient 1’s electronic medical record (EMR) indicated the occupational therapy (OT) notes for 10/31/2022, 11/2/2022, and 11/8/2022 were documented on 11/14/2022 by the OT. It also indicated, the physical therapist (PT) notes for 11/9/2022 were documented on 11/14/2022. A review of Patient 2’s “Patient Information” indicated a start of care (SOC) date of 6/27/2022 and a primary diagnosis of Type 2 Diabetes (high blood sugar). Patient 2’s nursing notes were requested on 11/14/2022, however no notes were provided. During a record review on 11/15/2022, at 10:30 a.m., of Patient 2’s electronic medical record (EMR), indicated the nursing notes for 11/3/2022 and 11/10/2022 were documented on 11/14/2022 by License Vocational Nurse 1 (LVN1). It also indicated Patient 2’s recertification OASIS that was dated 10/24/2022 was documented on 11/2/2022. A review of Patient 3’s “Patient Information” indicated a start of care of 11/3/2022, diagnosis section has been left blank. A concurrent interview and record review on 11/14/2022, at 2:40 p.m., with Administrator (ADM) of Patient 3’s EMR indicated there was no initial OASIS (Outcome and Assessment Information Set - a standardized data set that measures quality and outcomes. It contains information regarding the patient such as the clinical condition, comorbidities, physical and mental state, functional status, living situation and health care needs.), Plan of Care (POC), Medication profile, Physical Therapy or Nursing notes documented on Patient 3’s EMR. ADM stated, “I don’t see anything, whether they were in contact with patient. I have to call them to find out what happened.” A review of Patient 5’s profile indicated a start of care date (SOC) of 7/26/22, with diagnoses including Alzheimer’s Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation.) A review of Patient 5’s medical record indicated Physical Therapy visits of once a week for 6 weeks. Continued review of the record did not indicate Physical Therapy notes for the week of 11/6/22. During an interview on 11/15/2022, at 12:40 p.m., with ADM, stated, “As it stands, we don’t document late entry anywhere. I don’t have a late entry policy. I have to take a look at what consist of late entry and see if I can develop something.” During an interview on 11/15/2022, at 1:35 p.m., with ADM, stated, “We are late in documenting”. A review of the agency’s policy and procedure titled, “Skilled Nursing Services” dated 2/02, indicated “Registered Nurse duties include… j. Prepare timely clinical and progress notes… License Vocational Nurse duties include… d. Prepare timely clinical notes…” A review of the agency’s policy and procedure titled, “Coordination of Services”, dated 7/2020, indicated “The comprehensive assessment/OASIS assessment is not required to be completed at the initial visit but no later than five calendar days after the start of care.” A review of the agency’s policy and procedure titled, “OASIS Assessment”, dated 5/2017, indicated “The Case Manager: b. Documents the initial assessment on the Nursing Assessment form. c. Begins the patient Plan of Care based on the assessment data obtained in the initial visit”. A review of the agency’s policy and procedure titled, “Clinical Record”, dated 7/2008, indicated “1. The clinical record includes the following: a. Admission record. d. Plan of Care. n. Clinical notes by all multidisciplinary members. 2. Clinical records are: a. Kept current and in detail to identify the patient’s health status for health care providers.”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for two of seven sampled patients (Patient 6 and Patient 7). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. Findings: A review of Patient 6’s profile indicated a start of care date (SOC) of 3/16/22, with diagnoses including pressure ulcer of left buttock, stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful.) A review of Patient 7’s profile indicated a start of care date (SOC) of 12/15/21, with diagnoses including encounter for surgical after following surgery on the circulatory system. During an interview on 11/15/22, at 2:30 p.m., the administrator (ADM) stated the discharge summary (DC-a document summarizing the care provided by the home health agency) was sent to the doctor as soon as all notes were submitted. The ADM stated Patient 6’s discharge date from nursing services was 4/5/22 and the DC summary was sent to the doctor on 5/10/22. The ADM stated Patient 7’s discharge date from nursing services was 1/5/22 and the DC summary was sent to the doctor on 2/10/22. A review of the agency’s policy and procedure titled, “Care Summary Reports”, dated 2/2002, indicated, “Procedure Discharge/Care Summary Reports: 3. The Discharge/Care Summary is submitted to the Clinical Supervisor with 30 calendar days of the discharge date. It is available to the physician upon request…”