Every finding on record at Amedisys Missouri, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 05/30/2024.During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 05/30/2024. The provider had 129 current patients.

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 policy review, record review, observation, and interview, the home health provider failed to ensure staff maintained an accurate/updated medication profile in two of three home visit observations (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the record showed the patient was admitted to home health services on 04/23/2024. The patient had a history of extradural abscess (an infection in the space between the bones of the skull or spine and the membranes that cover the brain and spinal cord) and subdural abscess (a brain infection). Review of a physical therapy (PT) evaluation note dated 04/24/2024, showed the patient used acetaminophen (Tylenol) for pain. This was not included on the medication profile. Observation and interview on 05/13/2024 beginning at 12:10 PM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: - The RN (registered nurse) reviewed the patient’s medications; - The medication profile showed an order for dextroamphetamine-amphetamine (a stimulant medication used to treat attention deficit hyperactivity disorder (ADHD) 10 milligrams (mg) four tablets daily. The patient had a bottle dated 01/25/2024, of amphetamine 10 mg two in the morning and one at noon. The patient stated that he/she had taken this dosage about six months or longer; - The medication profile showed an order for metformin (diabetes medication) 500 mg one daily. The patient stated that he/she had not taken this in quite a while; - The medication profile showed an order for methocarbamol (muscle relaxant) 500 mg every eight hours. The patient had a bottle dated 05/06/2024, of methocarbamol 500 mg take one to two tablets three times a day as needed; - The medication profile showed an order for miralax (laxative) 17 grams daily. The patient stated that he/she had never gotten this to use; - The patient had a bottle of vitamin D3 (supplement) 25 micrograms (mcg) 1000 IU (international units). The patient stated that he/she had taken one once a day for about a month. The patient’s spouse stated that he/she had taken this for about a year. This was not included on the medication profile; and - The patient had a bottle dated 02/07/2024, of lactobacillus acidophilus (probiotic for gut health) one tablet once a day. The patient stated that he/she had taken this for at least a year. This was not included on the medication profile. During an interview on 05/29/2024, beginning at 1:15 PM, the area vice president of operations stated that if a patient was not taking a medication, he/she would not want it included on the medication list. The staff should visualize the medications at every visit. The administrator stated that staff should notify the physician if a patient was not taking a medication. The process was to go over all the medication bottles and compare to the discharge medication list and notify the physician of any discrepancies. If PT identified a new medication, they should contact the physician, write an order, update the medication profile, and let the clinical manager know. Findings included: Review of the provider’s policy titled, “Drug Regimen Review,” last revised December 1, 2023, showed in part: - The purpose of the policy is to identify appropriateness, inconsistencies and /or significant drug interactions as well as ensure a comprehensive list of medications are updated any time there is a medication change including dose change, new medications, and any medications discontinued; and - A copy of the Medication Profile is taken to the patient’s home and placed in the patient’s home folder and incorporated in the medical record. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 05/16/2024 with a primary diagnosis of a fracture to the right hip, and diabetes (a condition of excess sugar in the blood).The patient lived at home with his/her spouse. Observation and interview on 5/28/2024 at 12:00 PM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for B-Complex tablet (a vitamin supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Berberine Chloride 500 milligram (mg) capsule (a vitamin supplement), one capsule daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Hydrocodone 10 mg - Acetaminophen 325 mg tablet (a narcotic pain reliever), one tablet every 6 hours as needed daily. The patient stated that he/she no longer takes the medication; -The medication profile showed an order for Kidney Activator tablet 830 mg (a dietary supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Losartan 25 mg tablet (a medication to lower blood pressure), one tablet two times daily. The patient stated that he/she no longer takes the medication since 5/15/2024; -The medication profile showed an order for Magnesium Complex 300 mg (a vitamin supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Probiotic 1 billion cell chewable tablet (a dietary supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Turmeric Curcumin 1000 mg tablet (a dietary supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Turmeric 750 mg tablet (a dietary supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Vitamin C 250 MG tablet (a vitamin supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; -The medication profile showed an order for Vitamin D3 125 micrograms (mcg) tablet (a vitamin supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization; and -The medication profile showed an order for Zinc Gluconate 50 mg tablet (a vitamin supplement), one tablet daily. The patient stated that he/she no longer takes the medication after her hospitalization. Additionally, the patient stated during the home visit he/she currently was taking the following medications which were in the home but were not listed on the current mediation list supplied by the provider; -The medication Tylenol 500 mg tablet (a non-narcotic pain reliever), one to two tablets as needed daily. The patient stated that this was used for his/her pain shorty after returning home from the hospital; and -The medication Pure Enzyme Ultra (a dietary supplement), one to two tablets as needed daily. The patient stated that he/she currently takes the medication. During an interview on 05/29/2024 at 1:30 PM, the administrator stated that the staff should follow the medication policy which directs the staff to compare all medications in the home to the medication list. Any discrepancies should be corrected by contacting the patient's physician for clarification, and the patient’s current medication list should then be updated. RECORD/PATIENT #3: Review of the record showed the patient was admitted to home health services on 04/23/2024. The patient had a history of extradural abscess (an infection in the space between the bones of the skull or spine and the membranes that cover the brain and spinal cord) and subdural abscess (a brain infection). Review of a physical therapy (PT) evaluation note dated 04/24/2024, showed the patient used acetaminophen (Tylenol) for pain. This was not included on the medication profile. Observation and interview on 05/13/2024 beginning at 12:10 PM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: - The RN (registered nurse) reviewed the patient’s medications; - The medication profile showed an order for dextroamphetamine-amphetamine (a stimulant medication used to treat attention deficit hyperactivity disorder (ADHD) 10 mg four tablets daily. The patient had a bottle dated 01/25/2024, of amphetamine 10 mg two in the morning and one at noon. The patient stated that he/she had taken this dosage about six months or longer; - The medication profile showed an order for metformin (diabetes medication) 500 mg one daily. The patient stated that he/she had not taken this in quite a while; - The medication profile showed an order for methocarbamol (muscle relaxant) 500 mg every eight hours. The patient had a bottle dated 05/06/2024, of methocarbamol 500 mg take one to two tablets three times a day as needed; - The medication profile showed an order for Miralax (laxative) 17 grams daily. The patient stated that he/she had never gotten this to use; - The patient had a bottle of vitamin D3 (supplement) 25 mcg 1000 IU (international units). The patient stated that he/she had taken one once a day for about a month. The patient’s spouse stated that he/she had taken this for about a year. This was not included on the medication profile; and - The patient had a bottle dated 02/07/2024, of lactobacillus acidophilus (probiotic for gut health) one tablet once a day. The patient stated that he/she had taken this for at least a year. This was not included on the medication profile. During an interview on 05/29/2024, beginning at 1:15 PM, the area vice president of operations stated that if a patient was not taking a medication, he/she would not want it included on the medication list. The staff should visualize the medications at every visit. The administrator stated that staff should notify the physician if a patient was not taking a medication. The process was to go over all the medication bottles and compare to the discharge medication list and notify the physician of any discrepancies. If PT identified a new medication, they should contact the physician, write an order, update the medication profile, and let the clinical manager know.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 09/23/2021. During the survey it was determined Amedisys Home Health of Missouri is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Amedisys Home Health of Missouri was completed on 09/23/2021. The agency had 126 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on nationally recognized standard, agency policy, OASIS guidance, clinical record review, and interview, the agency failed to ensure that encoded Outcome and Assessment Information Set (OASIS) data accurately reflected the patient's status at the time of assessment in two (Record/Patient #7, and #8) of six records reviewed for OASIS accuracy. This deficient practice has the potential to affect accuracy of all OASIS data encoded by the agency. Findings included: Review of the document effective 01/01/2020 and titled, "OASIS-D1 Update for CY 2020," showed that the posted OASIS-D Guidance Manual, along with this updated document, will serve as guidance for OASIS-D1. There is no revised version of the OASIS-D Guidance Manual. Review of the document effective 01/01/2019 and titled, "Outcome and Assessment Information Set, OASIS D Guidance manual," showed: - "In any data-driven system, the quality of the output is only as good as the quality of the data input. OASIS data are used for multiple purposes, including production of quality reports for agencies, public reports on the Medicare Home Health Compare website, and to determine payment. Thus, it is imperative that the OASIS data that HHAs collect and submit be accurate and complete." ; and - The M0090, date assessment completed, will indicate the last day the clinician gathered or received any input used to complete the comprehensive assessment document, which includes the OASIS items. Review of OASIS guidance dated 07/2018 and titled, "Home Health OASIS July 2018 Quarterly Q & As,"the answer to question two showed that in the case of an unplanned or unexpected discharge (an end of home care where no in-home visit can be made), the last qualified clinician who saw the patient may complete the discharge comprehensive assessment document based on information from his/her last visit. The assessing clinician may supplement the OASIS items on the discharge assessment with information documented from patient visits by other agency staff that occurred in the last 5 days that the patient received visits from the agency prior to the unexpected discharge. The "last 5 days that the patient received visits" are defined as the date of the last patient visit, plus the four preceding calendar days. Review of the agency policy dated 03/25/2021 and titled, "Oasis Outcome and Information Set," showed that the encoded Oasis data must accurately reflect the patient's status at the time of assessment. RECORD/PATIENT #7: Review of the last qualified clinician visit documentation dated 04/21/2021 showed that the patient was unable to take medication unless administered by someone else. Review of the non-visit OASIS discharge dated 05/19/2021 showed: - The date assessment completed (M0090) was 05/19/2021; - The documentation contained in the last qualified clinician visit showed the answer to M2020 as 3 - unable to take medication unless administered by another person; and - The visit note addendum for quality assurance showed the answer to M2020 was changed to, "2 able to take medications at the correct times if given reminders by another person at the appropriate times. The visit documentation of the last qualified clinician failed to support the change made by the quality assurance staff. RECORD/PATIENT #8: Review of the discharge summary dated 04/09/2021 showed the last visit made by any agency staff member was 03/15/2021. Review of the non-visit OASIS discharge dated 03/28/2021 showed the date assessment completed (M0090) was 03/28/2021. Per guidance, the M0090 date must reflect the date of the last clinician visit performed used to complete the OASIS discharge. The M0090 date should not have been after 03/15/21.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, review of the current patient rights information, record review, home visit observation and interview the agency failed to ensure the staff provided a written visit schedule to the patients that included what discipline was visiting and the frequency of visits in one (Patient/Record #1) of three home visits. This deficient practice has the potential to affect the patient and caregiver ability to know in advance when to expect services to be provided for all patients served by the agency. Findings included: Review of the agency ' s policy titled "Patient Rights and Responsibilities", dated last reviewed 6/24/21, showed in part: -The patient has the right to participate in, be informed about, consent or refuse care in advance of and during treatment, where appropriate, with respect to: *The disciplines that will furnish care; and *The frequency of visits. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency 7/29/2021 with infection and inflammatory reaction due to other cardiac (heart) and vascular devices, implants (medical device manufactured to replace a missing biological structure) and grafts for wound care and a history of dilated cardiomyopathy (a disease of the heart muscle that usually starts in the heart ' s main pumping chamber causing it to stretch and thin (dilate) leaving it unable to pump blood as well as a healthy heart can). Review of the plan of care (POC) dated 7/29/2021 through 9/26/2021 showed: - SN (skilled nursing) 2wk5, 1wk4 + 2 prn (as needed) visits for wound vac (vacuum-assisted closure of a wound- a type of therapy to help wounds heal) or IV (intravenous) complications. - Resumption of care order dated 8/17/2021, showed SN effective 08/15/2021 2wk4, 1wk1, 2wk1. During a home visit observation on 09/14/2021 starting at 1:55 PM, review of the admission folder showed a form that stated: - While you are a patient of Amedisys Home Health it is our job to keep you up to date on your visit schedule; - We will do this by providing you with a patient instruction sheet once your plan of care has been approved; and - Please see below scheduled visit plan at Start of Care/Post Eval (after evaluation): * Column one titled "Week of" showed: 7/29/21 SOC written below; and * Column two titled "Discipline and # of visits planned" showed: "1xwkx1wk, 2xwkx8 wks". The agency failed to show changes in frequency of visits with order changes and clear specific days of visits as well as the discipline visiting. During an interview on 9/14/2021 during the home visit observation starting at 1:55 PM the patient stated that: - His/her visit days change due to doctor appointments; - The nurse discusses the upcoming visits during the current visit; and - Nothing in writing is provided as to what days of the week the discipline is coming. The review of the visit schedule findings in the home were presented to the designated alternate administrator on 09/15/2021 at 4:25 PM and no further information was provided.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to ensure staff provided in writing the name and contact information of the clinical manager in three (Record/Patient #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: During a home visit observation on 09/14/2021 starting at 1:55 PM with skilled nursing, the surveyor observed the patient's home folder. The folder in the home failed to show the name and contact information of the agency's clinical manager. RECORD/PATIENT #2: During a home visit observation on 09/14/2021 starting at 12:55 PM with the physical therapist, the surveyor observed the patient's home folder. The folder in the home failed to show the name and contact information of the agency's clinical manager. RECORD/PATIENT #3: During a home visit observation on 09/14/2021 at 11:35 AM, the patient stated that he/she did not know the name of the clinical manager, and he/she was unable to locate the clinical manager name in the admission folder in the home. During an interview with RN A while on a home visit observation on 09/14/2021 starting at 1:55 PM, RN A stated that: - He/she was surprised the clinical manager and contact information was not present in the home folder; and - Springfield (a sister agency) had a sticker on the front of their home folder. That was so nice. Then I knew who the clinical manager was. The findings were reviewed with the designated alternate administrator on 09/15/2021 at 3:50 PM and no other information was provided.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on accepted standards of practice, policy review, record review, home visit observation and interview, the agency failed to ensure accepted standards of practice were used during wound care in one (Record/Patient #1) out of three home visits observed. This deficient practice has the potential to adversely affect the safety from infection of all the agency ' s patient ' s receiving wound care. Findings included: According, in part, to McGoldrick, M. (2015), Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc., the following guiding principles should be considered to reduce the risk of product contamination and subsequent patient infection when utilizing irrigation solution: - Use the smallest (e.g., 50ml (milliliter)) container of solution whenever possible on a one-time basis; - When using a container of solution that will be used on multiple, separate occasions, write the "discard by" date on the container; and - If solution (e.g., normal saline) is left over in the smaller container (e.g., 50 ml) after the intended amount has been removed, do not save the leftover content and combine it or top it off for later use. Review of the agency ' s policy titled "The Provision of Wound and Skin Care" date revised 09/18; 2/25/21, showed in part (when sterile normal saline is part of wound care orders) : - Once a bottle is opened, the clinician should write the date, time and their initials on any re-sealable bottle that will be used again within 24 hours; - Any excess saline remaining after 24 hours should be discarded; and - Non re-sealable 100 ml bottles of saline are for one time use only. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency 7/29/2021 with infection and inflammatory reaction due to other cardiac (heart) and vascular devices, implants (medical device manufactured to replace a missing biological structure) and grafts for wound care and a history of dilated cardiomyopathy (a disease of the heart muscle that usually starts in the heart ' s main pumping chamber causing it to stretch and thin (dilate) leaving it unable to pump blood as well as a healthy heart can). Review of the physician order dated 8/20/2021 showed in part: -Skilled nurse to perform/teach patient/caregiver wound care to left chest; - Cleanse with normal saline and pat dry with gauze; and - Pack with sterile normal saline moistened gauze. During a home visit observation on 09/14/2021 starting at 1:55 PM, the RN (registered nurse) was observed completing the left chest wound care. The RN failed to maintain infection control standards when he/she; - Used an undated, opened, partially filled 100 ml (milliliter) bottle of normal saline with the word "old" handwritten on it to cleanse the wound and to moisten the gauze for packing the wound; and - Placed the lid back on the bottle and returned it to the box containing dressing supplies. During an interview with the designated alternate administrator on 09/15/2021 at 4:25 PM, he/she stated that he/she: - Assumed you go by the expiration date regarding when to dispose of a 100 ml bottle of normal saline after opening; - Will check the policy; and - "I want to say after 30 days the opened bottle of normal saline is to be discarded, but I will check the policy."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide services as ordered by the physician on the plan of care (POC) in, but not limited to, two (Record/Patient #1 and #3) of five records reviewed. This deficient practice has the potential to adversely affect all patients served by the agency. Findings included: Review of the agency's policy dated last reviewed 6/24/2021, titled "Services Provided/Supervision of Disciplines- RN (registered nurse)/LPN (licensed practical nurse) showed in part: - Skilled professionals must assume responsibility for, but not be restricted to the following; * Providing services that are ordered by the physician as indicated in the plan of care. - Registered Nurse responsibilities must assume responsibility for, but not be restricted to the following; * Providing services that are ordered by the physician as indicated on the plan of care. - Licensed Practical Nurse services must be provided in accordance with the plan of care, may include but not limited to; *Performing body systems monitoring as outlined on care plan and as directed by RN; and *Education under the supervision of a registered nurse. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency 7/29/2021 with infection and inflammatory reaction due to other cardiac (heart) and vascular devices, implants (medical device manufactured to replace a missing biological structure) and grafts for wound care and a history of dilated cardiomyopathy (a disease of the heart muscle that usually starts in the heart's main pumping chamber causing it to stretch and thin (dilate) leaving it unable to pump blood as well as a healthy heart can). Review of the plan of care date 07/29/2021 through 09/26/2021 showed, in part: - Skilled Nurse (SN) to perform lab draw from access device (a device used to obtain access to one of the body's fluid compartments). Draw weekly; and - Skilled nurse to draw labs via venipuncture if unable to draw via vascular access device. CBC (complete blood count to evaluate the cells that circulate in blood), BMP (basic metabolic panel -a blood test that measures your sugar level, electrolyte and fluid balance, and kidney function), and CK(creatine kinase- a blood test used to detect inflammation of muscles or muscle damage) weekly. Review of the SN visit report note dated 8/06/2021 showed: - "SN91- SN LAB DUE"; and - "WERE LABS OBTAINED? YES" Review of the SN visit report note dated 8/10/2021 showed: - "SN91- SN LAB DUE"; and - "WERE LABS OBTAINED? YES" Resumption of care order dated 08/17/2021 showed: - Patient hospitalized at Freeman Health System- Freeman West 08/12/2021 through 08/16/2021; - Labs to be drawn next week of BMP, CBC w/Diff via venipuncture and fax results. Review of SN visit notes dated 08/24/2021 and 08/27/2021 failed to show documentation of labs being obtained. Clinical record review failed to show any lab results. During an interview 09/15/2021 starting at 4:25 PM with the designated alternate administrator a copy of the lab results was requested from 08/06/2021, 08/10/2021 and the week of 08/22/21 through 08/28/2021 as ordered by physician. CBC, BMP and CK results dated 08/10/2021 were given to surveyor. No further lab results were found. The designated alternate administrator stated that if Freeman (hospital) didn't have them then we aren't going to find them. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted for home health services on 07/02/2021 with diagnoses including, but not limited to, diabetes (a condition in which the body produces insufficient insulin (a hormone that helps the body use sugar in the blood) to meet the metabolic needs of the body, and atrial fibrillation (a condition in which the heart's upper chambers (the atria) beat chaotically and irregularly and are out of sync with the lower chambers (the ventricles) of the heart leading to shortness of breath, weakness, and an increase risk of blood clot formation. EXAMPLE 1: Review of the plan of care (POC) with certification dates of 07/02/2021 to 08/30/2021 showed: - Orders for anticoagulant management for warfarin including: * Nurse to assess; * Teach and monitor effectiveness of anticoagulation therapy; and * Nurse to instruct on signs and symptoms of bleeding/adverse reactions to report to physician; and - Orders for diabetes management including: * Nurse for instruction of diabetic care to include diet, skin care, signs and symptoms of hypo/hyperglycemia (low/high blood glucose level), proper administration of diabetic medication; * Nurse assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings to physician; * Nurse may perform blood glucose test as needed; * Skilled nurse to report to physician blood glucose readings greater than 300 or less than 70; - Orders for pain management including nurse to observe, assess, and provide education on pain management. Review of nursing visits performed on, but not limited to, 07/02/2021, 07/07/2021, and 07/09/2021, showed the documentation failed to contain: - Teaching and monitoring of anticoagulation therapy, instruction on signs and symptoms of bleeding/adverse reactions; - Instruction on diabetic care including diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication. a diabetic assessment including client's ability to self monitor blood sugars or history of blood sugar readings; assessment patient/caregiver ability to perform and record blood glucose testing, and - Education on pain management techniques. EXAMPLE 2 : Review of add-on discipline order for physical therapy dated 07/09/2021 showed orders to notify physician if the patient rated pain greater than seven out of ten (on a zero to ten high scale). Review of physical therapy assistant visit documentation performed on, but not limited to,: - 07/13/2021 showed the patient had pain rated nine at worst in the past 24 hours; - 07/16/2021 showed the patient had pain rated eight at the worst in the past 24 hours; and - The documentation for each visit failed to contain notification of the physician for pain rated greater than a seven out of ten (on a zero to ten high scale). On 09/16/2021 at 11:00 AM, the designated alternate administrator stated that they would not be able to provide additional documentation for this patient.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on policy review and interview, the agency failed to ensure that the agency selected qualifying service of skilled nursing was provided directly by the agency. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Administrator/Clinical supervision Authorization" last updated on 06/24/2021 showed in part the following: - The administrator must ensure that the HHA (home health agency) employs qualified personnel, including assuring the development of personnel qualifications and policies; - Agencies must adhere to the most stringent regulations (state, federal, accreditation, professional practice, etc.); and - The administrator must be responsible for maintenance of compliance with federal, state, and local laws and regulations and standards (including preparation, completion, submission, and filing of all records and reports mandated within specific time requirements). During the entrance interview with the administrator on 09/13/2021 at 4:15 PM, he/she stated the following: - The qualifying service for the HHA is skilled nursing services; and - The agency has contracted staff that includes skilled nurses. During an interview with the designated alternate administrator on 09/15/2021 at 4:00 PM, he/she reported that the HHA will change the qualifying service to be a service that is directly provided by the agency.