Every finding on record at Americare in Home Nursing - Jar, Inc

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Virginia Department of Health, Health Facility Survey and Field Operations. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 08/13/25 to 08/15/25 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Virginia Department of Health, Health Facility Survey and Field Operations. An unannounced on-site Recertification Survey conducted at the above named Home Health Agency (HHA) from 08/13/25 to 08/15/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on document review, interview, and policy review, the Home Health Agency (HHA) failed to complete an initial assessment visit within 48 hours of a referral, or the patients return home from an inpatient facility stay, or on the practitioner ordered start of care date for four of eight patients (Patient (P) 1, P2, P4, and P8). The delay in the initial assessment had the potential to affect patient safety or delay identification of signs or symptoms of health concerns which could result in rehospitalization. Findings include: Review of the agency's policy titled, "Referral/Intake Coordination," dated May 2024, revealed "The admitting clinician will plan to see the patient within 48 hours of the referral or on the date requested by physician or patient/family." The agency policy did not include that the practitioner would need to be contacted to change the start of care date if the patient or family member requested a delay. 1. Review of P1's electronic medical record (EMR) revealed a referral located in the "Misc" tab, dated 08/07/25, for home health physical therapy (PT) and occupational therapy (OT) following an inpatient hospital stay from 07/29/25 to 08/04/25. Review of a note, dated 08/11/25, four days after the referral, located in the EMR in the "Communication" tab, written by the Clinical Manager (CM), revealed "This writer called NP [Nurse Practitioner] notifying the provider of delayed SOC [start of care] per patient's request." Review of P1's "OASIS [Outcome and Assessment Information Set] E-1 Start of Care" assessment located in the EMR in the "PT" tab, revealed the PT completed the initial visit on 08/11/25. 2. Review of P2's EMR revealed a referral located in the "Misc" tab, dated 07/18/25, for PT services due to osteoarthritis in both knees. Review of P2's "OASIS E-1 Start of Care" assessment located in the EMR in the "PT" tab, revealed the PT completed the initial visit on 07/24/25. 3. Review of P4's EMR revealed a signed practitioner order, dated 07/10/25, located in the "Misc" tab for "Home PT/OT eval and treat" following a hospital and rehabilitation stay due to a pubic bone fracture following a fall at home. Review of a "Patient Communication," dated 07/10/25, located in the "Communication" tab, revealed "Transition and completed referral from [name of marketer] on 07/09/25 … D/C [Discharge] 7/11, SOC 7/14 [son of patient] asking for afternoon appt." Review of P4's "OASIS E-1 Start of Care" assessment located in the EMR in the "PT" tab revealed the PT completed the initial visit on 07/14/25. Further review of P4's EMR failed to show the licensed practitioner was consulted regarding the delay in the SOC. 4. Review of P8's EMR revealed a document titled, "Face to Face Note/Home Health Orders," dated 06/20/25, located in the "Misc" tab. The document included physician orders for home health skilled nursing (SN), PT, and OT following an inpatient hospital stay due to an acute intraparenchymal hematoma (a type of stroke where bleeding occurs within the brain tissue itself). Review of a document titled, "Discharge/Transfer Summary," located in the "Misc" tab in the EMR revealed P8 was admitted to [Name] Hospital on 06/14/25 and discharged on 06/20/25. Review of P8's "OASIS E-1 Start of Care" assessment located in the EMR in the "SN" tab, revealed the Registered Nurse (RN) completed the initial visit on 06/24/25. During an interview on 08/14/25 at 9:30 AM, the Administrator stated that the agency was part of a larger corporation and that it utilized a "referral process" which obtained referrals either through marketers or a referral platform and that the "intake department" received the referrals, verified insurance, and availability of staff prior to the agency being notified of the referral in most cases. During an interview on 08/15/25 at 3:45 PM, the Administrator confirmed that the identified patient's start of care visits occurred more than 48 hours after the referral or inpatient facility discharge date.

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 document review, interview, and policy review, the Home Health Agency (HHA) failed to complete the patient comprehensive assessment no later than five calendar days after the start of care for three of eight patients (Patient (P) 3, P5, and P8). The failure to complete a thorough patient assessment in a timely manner could affect the determination of services needed to meet the patient's goals. Findings include: Review of the agency's policy titled, "Comprehensive Assessment of Patients," dated April 2024, revealed the following regarding the start of care (SOC) OASIS (Outcome and Assessment Information Set) assessment, "Initiate during the start of care visit and complete during that visit whenever possible … no later than five calendar days after the start of care date." 1. Review of P3's "OASIS-E1 Start of Care" assessment located under the "SN" (skilled nursing) tab in the electronic medical record (EMR) revealed a SOC date of 07/03/25. Review of a "Patient Communication" note, dated 08/07/25, located under the "Communication" tab in P3's EMR, revealed changes were made in the comprehensive OASIS patient assessment in the following areas: 1. Transferring and 2. Management of Oral Medications. The note states, "Locking the OASIS assessment indicates clinician approval of post-review edit corrections." During an interview on 08/15/25 at 3:45 PM, the Administrator confirmed changes were made to P3's Comprehensive OASIS assessment and provided a lock date verifying completion of assessment of 08/11/25. 2. Review of P5's "OASIS-E1 Start of Care" assessment located under the "SN" tab in the EMR revealed a SOC date of 05/08/25. Review of a "Patient Communication" note, dated 05/22/25, located under the "Communication" tab in P5's EMR, revealed multiple changes were made to the responses in the comprehensive OASIS patient assessment including the following areas: 1. Ability to dress upper body, 2. Ability to dress lower body, 3. Bathing, 4. Toileting, 5. Transferring, 6. Ambulation, 7. Oral hygiene, 8. Mobility, and 9. Management of oral medication. During an interview on 08/15/25 at 3:45 PM, the Administrator confirmed changes were made to P5's Comprehensive OASIS assessment and provided a lock date verifying completion of the assessment of 05/23/25. 3. Review of P8's "OASIS-E1 Start of Care" assessment located under the "SN" tab in the EMR revealed a SOC date of 06/24/25. Review of a "Patient Communication" note, dated 07/16/25, located under the "Communication" tab in P8's EMR, revealed multiple changes were made to the responses in the comprehensive OASIS patient assessment including the following areas: 1. Ability to dress upper body, 2. Ability to dress lower body, 3. Toilet transferring, 4. Toileting hygiene, 5. Transferring, 6. Ambulation, 7. Hospitalization risk, 8. Management of oral medications. During an interview on 08/15/25 at 3:45 PM, the Administrator confirmed changes were made to P8's Comprehensive OASIS assessment and provided a lock date verifying completion of the assessment of 07/21/25.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on document review, interview, and policy review, the Home Health Agency (HHA) failed to provide the patient or caregiver with a written medication list which included the name of the medication, dosage, and frequency written in plain language for two of two patients (Patient (P) 3 and P4) reviewed during a home visit observation. This failure had the potential to contribute to medication errors which could result in patient harm. Findings include: Review of the agency's policy titled, "Medication Management," dated November 2021, revealed it failed to include that the agency completes and provides to the patient/caregiver a medication list written in plain language. Review of the agency's admission booklet provided to the patient/caregiver during the admission process showed it included a blank "Medication Profile" form. 1. Review of P3's admission booklet during a home visit observation on 08/15/25 at 1:00 PM revealed the "Medication Profile" form was not completed. 2. During P4's home visit observation on 08/14/25 at 1:00 PM, an interview with Family Member (F) 1 revealed they had not received a written list of medications from the HHA. F1 stated, "We got a list of medications from the hospital when [P4] was discharged." During an interview on 08/15/25 at 3:45 PM, the Administrator stated the staff person completing the admission comprehensive assessment was supposed to complete the "Medication Profile" form in the admission booklet after reviewing and reconciling the patient's medications. The Administrator confirmed that the agency did not have a policy that specifically stated that the medication list was to be completed and provided to the patient/caregiver.

An unannounced Home Health Agency recertification survey was conducted on November 29-30, 2021 by one (1) Medical Facilities Inspectors from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

An unannounced Home Health Agency recertification survey was conducted on November 29-20, 2021 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 21 duplicated admissions in the last twelve (12) months with an active census of 6 patients. The following were completed/reviewed in conjunction with the survey: Two (2) home visits, nine (9) clinical records, eight (8) personnel files, review of selected policies and procedures, complaint log, emergency preparedness plan and interviews were conducted. The agency was found to be out of compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs). Significant corrections are required due to substantial non-compliance with the following Conditions of Participation: 484.60 Care planning, coordination, quality of care

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 a review of clinical records, agency policies and interviews it was determined the agency staff failed to ensure the comprehensive assessment was completed for the initial assessment in one (1) of nine (9) clinical records reviewed in the survey sample (clinical record #1). The findings were: The electronic medical records were reviewed in read-only mode on 11/29-30/2021. Clinical record #1 was reviewed for the certification period of 10/25/2021 through 12/23/2021. The initial comprehensive assessment completed by the nurse to include OASIS (Outcome and Assessment Information Set) data was still not complete thirty-six days after the start of care. An interview with employee #2 at 2:55 PM on 11/29/2021 revealed the above findings are accurate and the nurse had not completed the documentation. An interview was conducted on 11/29/2021 at 12:56 PM with the nurse (employee #3) who provided care. The nurse presented a composition notebook and stated that is what is used to make notes during nursing visits. The nurse acknowledged failing to document in the electronic record during visits and being behind in entering the documentation into the electronic record. Employee #3 could not provide evidence of documentation in the book for patient #1 and stated "it must be in my other book". The employee stated having another book and that book was at home. A review of the book presented revealed very basic information on patients to include their name, date of visit and the patient's vital signs. When asked how employee #3 would remember what the patient's status was from a month ago, not having written it down, the employee stated "I know my patient's". A review of the agency policy titled "Comprehensive Assessment of Patients" stated in part: "Patients served by the agency will receive an initial /comprehensive assessment and subsequent comprehensive assessments conducted/updated at time periods specified in regulation." Page 3 of the policy continues with the definition and required time frame for assessments. The time given for the start of care (SOC) reads "Initiate during the start of care visit and complete during that visit whenever possible. When the patient's condition warrants less than a total assessment during that visit, complete in conjunction with an additional visit or contact with the patient's caregiver/family, no later than five calendar days after the start of care date.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy and staff interview, it was determined that the agency failed to update or revise the comprehensive assessment within 48 hours of a patient's return to the home from a hospital admission of 24 hours or more for one (1) of one (1) patient who had a resumption of care following a hospital admission in the survey sample (clinical record #2) The findings were: Clinical record #2 was reviewed for the certification period of 11/04/2021 through 01/02/2021. The electronic record visit schedule indicated a transfer of care on 11/12/2021 with a ROC (resumption of care) to be done on 11/18/2021. There was no visit note for the 11/18/2021 visit. An interview was conducted with employee #2 and #3 on 11/30/2021 at 12:56 PM. Employee #2 stated the visits are scheduled on the calendar and the days that are showing are the dates the visits were supposed to be made. Employee #3 stated having made the visit but failed to document the visit or the update to the comprehensive assessment in the electronic medical record. There is no written evidence of a complete assessment having been done. The nurse presented a composition notebook for review that had the date, patients name and vital signs for the date of resumption (11/18/2021) but no other relevant information. Employee #3 stated if there was a problem it would be in the book (personal notebook). A review of the agency policy titled "Comprehensive Assessment of Patients" stated in part: Patients served by the agency will receive an initial /comprehensive assessment and subsequent comprehensive assessments conducted/updated at time periods specified in regulation. Page 3 of the policy continues with the definition and required time frame for assessments. The time given for the resumption (ROC) reads "Complete during first visit following the patient's return to home from a hospital stay of 24 hours or more that was for any reason other than just diagnostic tests, or return from another inpatient facility. Must be completed within 48 hours of patient's return". As per the agency policy, the patient met the criteria to have a ROC completed and the nurse stated one had been completed however, no evidence was provided that the assessment had been completed.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on staff interviews and clinical record reviews it was determined the agency failed to provide care as ordered by a physician. Specifically, the agency failed develop a care plan for each patient (refer to G572); the agency failed to ensure that all plans of care were complete and accurate (refer to G574); the agency failed to ensure all physician orders were recorded in the plan of care (refer to G578); and the agency failed to obtain physician orders prior to providing nursing services (refer to G580);. During the course of the survey it was determined the skilled nursing staff was providing services without developing a plan of care. In addition, the skilled nurse failed to complete assessments, failed to document visits in the electronic record and failed to obtain physicians orders prior to providing care. The cumulative effect of this problem resulted in the agency's inability to provide evidence that a physician approved of the care provided and that nursing staff were providing safe and appropriate care to patients.

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 on clinical record review, agency policy review and interviews, it was determined the agency failed to ensure that each patient received their home health services according to a written plan of care for three (3) of nine (9) clinical records reviewed in the survey sample (clinical record #1, 3, and 4). The findings were: 1. Clinical record #1 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 10/25/2021. The electronic medical record (EMR) failed to contain a plan of care. 2. Clinical record #3 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/26/2021. The EMR failed to contain a plan of care. 3. Clinical record #4 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/13/2021. The EMR failed to contain a plan of care. The plan of care for clinical record #1 was requested from the clinical manager, employee #1 at approximately 12 PM on 11/29/2021 along with the care plans for other patients selected in the survey sample. No care plans were provided. An interview with employee #2 at 2:55 PM revealed the nurse did not do the care plan. Employee #2 acknowledged what was in the record was accurate and the nurse failed to complete required documentation. The nurse had been contacted related to late documentation. On 11/30/2021 at 8:45 AM the agency was able to provide the plans of care for clinical records #3 and #4 in order for this surveyor to make home visits to those patients. The plans of care had been created overnight after making contact with the nurse (employee #3). An interview was conducted with employee #1 on 11/30/2021 at 9 AM. The employee acknowledged being aware the employee was not current on documentation and stated all staff were counseled several weeks ago about the timeliness of documentation and given until December 1, 2021 to come into compliance. The employee stated believing that the nurse was taking notes on scrap paper during visits but acknowledge the nurse probably didn't write everything down and therefore relevant information could be lost. An interview was conducted with the nurse who provided care, employee #3 on 11/29/2021 at 12:56 PM. The nurse presented a composition notebook and stated that is what is used to make notes during nursing visits. The nurse acknowledged failing to document in the electronic record during visits and being behind in entering the documentation into the electronic record at a later date. Employee #3 could not provide evidence of documentation in the book for patient #1 and stated "it must be in my other book". The employee stated having another book and that book was at home. A review of the book presented revealed very basic information on patients to include their name, date of visit and the patient's vital signs. When asked how employee #3 would remember what the patient's status was from a month ago, not having written it down, the employee stated "I know my patient's". The employee acknowledged getting the written notice of failure to document in a timely manner. A review of the policy titled "Care Planning Process" reads in part: An individualized plan of care will be established, updated, and revised for all patients admitted to the agency. The plan will be based on identified patient problems/needs in order to promote achievement of desired outcomes, provide interventions in accordance with acceptable standards of care and the physician's orders, and to ensure consistency/continuity of care, and progress towards goals. The policy does not specify a time frame for completion of the care plan after admission.

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 clinical record review, agency policy review and interviews, it was determined the agency failed to ensure that each patient had a plan of care which contained the necessary elements for three (3) of nine (9) clinical records reviewed in the survey sample (clinical record #1, 3, and 4). Specifically, no plan of care had been developed for the three patients. The findings were: 1. Clinical record #1 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 10/25/2021. The electronic medical record (EMR) failed to contain a plan of care. 2. Clinical record #3 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/26/2021. The EMR failed to contain a plan of care. 3. Clinical record #4 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/13/2021. The EMR failed to contain a plan of care. The plan of care for clinical record #1 was requested from the clinical manager, employee #1 at approximately 12 PM on 11/29/2021 along with the care plans for other patients selected in the survey sample. No care plans were provided. An interview with employee #2 at 2:55 PM revealed the nurse did not do the care plan. Employee #2 acknowledged what was in the record was accurate and the nurse failed to complete required documentation. The nurse had been contacted related to late documentation. On 11/30/2021 at 8:45 AM the agency was able to provide the plans of care for clinical records #3 and #4 in order for this surveyor to make home visits to those patients. The plan of care had been created overnight after making contact with the nurse (employee #3). An interview was conducted with employee #1 on 11/30/2021 at 9 AM. The employee acknowledged being aware the employee was not current on documentation and stated all staff were counseled several weeks ago about the timeliness of documentation and given until December 1, 2021 to come into compliance. The employee stated believing that the nurse was taking notes on scrap paper during visits but acknowledge the nurse probably didn't write everything down and therefore relevant information could be lost. An interview was conducted with the nurse who provided care, employee #3, on 11/29/2021 at 12:56 PM. The nurse presented a composition notebook and stated that is what is used to make notes during nursing visits. The nurse acknowledged failing to document in the electronic record during visits and being behind in entering the documentation at a later date. Employee #3 could not provide evidence of documentation in the book for patient #1 and stated "it must be in my other book". The employee stated having another book and the book was at home. A review of the book presented revealed very basic information on patients to include the name, date of visit and the patient's vital signs. When asked how employee #3 would remember what the patient's status was from a month ago, not having written it down, the employee stated "I know my patient's". The employee acknowledged getting the written notice of failure to document in a timely manner. A review of the policy titled "Care Planning Process" reads in part: An individualized plan of care will be established, updated, and revised for all patients admitted to the agency. The plan will be based on identified patient problems/needs in order to promote achievement of desired outcomes, provide interventions in accordance with acceptable standards of care and the physician's orders, and to ensure consistency/continuity of care, and progress towards goals. The policy does not specify a time frame for completion of the care plan after admission.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and interviews, it was determined the agency failed to ensure that all physician orders were recorded in the plan of care for three (3) of nine (9) clinical records reviewed in the survey sample (clinical record #1, 3, and 4). Specifically, no plan of care had been developed for the patients. The findings were: 1. Clinical record #1 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 10/25/2021. The electronic medical record (EMR) failed to contain a plan of care or physician orders. 2. Clinical record #3 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/26/2021. The EMR failed to contain a plan of care or physician orders . 3. Clinical record #4 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/13/2021. The EMR failed to contain a plan of care or physician orders. The plan of care for clinical record #1 was requested from the clinical manager, employee #1 at approximately 12 PM on 11/29/2021 along with the care plans for other patients selected in the survey sample. No care plans were provided. An interview with employee #2 at 2:55 PM revealed the nurse did not do the care plan. Employee #2 acknowledged what was in the record was accurate and the nurse failed to complete required documentation. The nurse had been contacted related to late documentation. On 11/30/2021 at 8:45 AM the agency was able to provide the plan of care/physician orders for clinical records #3 and #4 in order for this surveyor to make home visits to those patients. The plans of care had been created overnight after making contact with the nurse (employee #3). An interview was conducted with employee #1 on 11/30/2021 at 9 AM. The employee acknowledged being aware the employee was not current on documentation and stated all staff were counseled several weeks ago about the timeliness of documentation and given until December 1, 2021 to come into compliance. The employee stated believing that the nurse was taking notes on scrap paper during visits but acknowledge the nurse probably didn't write everything down and therefore relevant information could be lost. An interview was conducted with the nurse who provided care, employee #3 on 11/29/2021 at 12:56 PM. The nurse presented a composition notebook and stated that is what is used to make notes during nursing visits. The nurse acknowledged failing to document in the electronic record during visits and being behind in entering the documentation at a later date. Employee #3 could not provide evidence of documentation in the book for patient #1 and stated "it must be in my other book". The employee stated having another book and that book was at home. A review of the book presented revealed very basic information on patients to include the name, date of visit and the patient's vital signs. When asked how employee #3 would remember what the patient's status was from a month ago, not having written it down, the employee stated "I know my patient's". The employee acknowledged getting the written notice of failure to document in a timely manner. A review of the policy titled "Care Planning Process" reads in part: An individualized plan of care will be established, updated, and revised for all patients admitted to the agency. The plan will be based on identified patient problems/needs in order to promote achievement of desired outcomes, provide interventions in accordance with acceptable standards of care and the physician's orders, and to ensure consistency/continuity of care, and progress towards goals. The policy does not specify a time frame for completion of the care plan after admission.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and interviews, it was determined the agency failed to ensure that care was provided only according to physician orders for three (3) of nine (9) clinical records reviewed in the survey sample (clinical record #1, 3, and 4). The findings were: 1. Clinical record #1 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 10/25/2021. The electronic medical record (EMR) failed to contain a plan of care or physician orders. The patient received services from skilled nursing without an order. 2. Clinical record #3 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/26/2021. The EMR failed to contain a plan of care or physician orders . The patient received services from skilled nursing without an order. 3. Clinical record #4 was reviewed in the agency on 11/29/2021. The patient had a start of care date of 11/13/2021. The EMR failed to contain a plan of care or physician orders. The patient received services from skilled nursing without an order. The plan of care for clinical record #1 was requested from the clinical manager, employee #1 at approximately 12 PM on 11/29/2021 along with the care plans for other patients selected in the survey sample. No care plans/orders were provided. An interview with employee #2 at 2:55 PM revealed the nurse did not do the care plan. Employee #2 acknowledged what was in the record was accurate and the nurse failed to complete required documentation. The nurse had been contacted related to late documentation. On 11/30/2021 at 8:45 AM the agency was able to provide the plan of care/physician orders for clinical records #3 and #4 in order for this surveyor to make home visits to those patients. The plan of care/orders had been created overnight after making contact with the nurse (employee #3). An interview was conducted with employee #1 on 11/30/2021 at 9 AM. The employee acknowledged being aware the employee was not current on documentation and stated all staff were counseled several weeks ago about the timeliness of documentation and given until December 1, 2021 to come into compliance. The employee stated believing that the nurse was taking notes on scrap paper during visits but acknowledge the nurse probably didn't write everything down and therefore relevant information could be lost. An interview was conducted with the nurse who provided care, employee #3 on 11/29/2021 at 12:56 PM. The nurse presented a composition notebook and stated that is what is used to make notes during nursing visits. The nurse acknowledged failing to document in the electronic record during visits and being behind in entering the documentation at a later date. Employee #3 could not provide evidence of documentation in the book for patient #1 and stated "it must be in my other book". The employee stated having another book and that book was at home. A review of the book presented revealed very basic information on patients to include the name, date of visit and the patient's vital signs. When asked how employee #3 would remember what the patient's status was from a month ago, not having written it down, the employee stated "I know my patient's". The employee acknowledged getting the written notice of failure to document in a timely manner. A review of the policy titled "Care Planning Process" reads in part: An individualized plan of care will be established, updated, and revised for all patients admitted to the agency. The plan will be based on identified patient problems/needs in order to promote achievement of desired outcomes, provide interventions in accordance with acceptable standards of care and the physician's orders, and to ensure consistency/continuity of care, and progress towards goals. The policy does not specify a time frame for completion of the care plan/orders after admission.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and staff interviews, it was determined the agency's governing body failed to ensure organization and overall administrative duties related to the agency's ongoing functions were being maintained. Specifically, the clinical manager designated to oversee the day-to-day functions in the office failed to ensure staff were performing duties as assigned to include documentation in the clinical record. The findings were: 1. Clinical record reviews revealed a skilled nurse failed to complete a comprehensive assessment for two (2) of nine patients in the survey sample (clinical record #1 and 4). 2. Clinical record reviews revealed a skilled nurse failed to complete a transfer summary and resumption of care assessment for one (1) of one (1) patient in the survey sample (clinical record #2). 3. Clinical record reviews revealed a skilled nurse failed to develop a plan of care and obtain physician orders for three (3) of nine (9) patients in the survey sample (clinical record #1, 3, and 4). 4.Clinical record reviews revealed a skilled nurse failed to ensure the clinical records contained all required assessments, nursing notes and physician orders for four (4) of nine (9) patients in the survey sample (clinical record #1, 2, 3, and 4). 5. An interview with the clinical manager was conducted on 11/30/2021 at 9 AM. The clinical manager (employee #1) stated all employees had been counseled on "timeliness of getting paperwork in a few weeks ago". The staff were advised to have everything in by December 1, 2021. Employee #2 stated the nurse involved in missing documentation (employee #3) was one of the people counseled and "I believe visit notes are written on scrap paper". The clinical manager acknowledged not believing the employee wrote everything down or could remember everything from the visits. The clinical manager was aware the nurse had not gotten caught up despite the deadline. 6. An interview with the nurse (employee #3 on 11/30/2021 at 12:56 PM revealed the employee had been counseled on timeliness of documentation. The employee provided a composition notebook with notes from home visits. The visit notes contained basic information to include the date, patient name and vital signs. The nurse stated if anything was wrong at the visit it would be written down. The employee was asked about a tracking system to remember what notes still needed to be written. The nurse stated it would show up in red on the computer. The administrator who was present for the interview explained a report is run by administration that shows if there is outstanding/incomplete documentation.

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 a review of clinical records and interviews it was determined the agency staff failed to ensure all clinical notes and physician orders were entered in the clinical record for four (4) of nine (9) clinical records reviewed in the survey sample (clinical record #1, 2, 3, and 4). The findings were: 1. Clinical record #1 was reviewed for the certification period of 10/25/2021 through 12/23/2021. The clinical record failed to contain a completed initial comprehensive assessment and the clinical nurse note on 10/28/2021 was incomplete. The clinical record also failed to include a care plan and physician orders. 2. Clinical record #2 was reviewed for the certification period of 11/04/2021 through 01/02/2021. The clinical record failed to contain skilled nursing notes for 11/12/2021, 11/19/2021, 11/23/2021, and 11/30/2021. In addition, the clinical record failed to contain a transfer summary for 11/12/2021 and a resumption of care note for 11/18/2021. 3. Clinical record #3 was reviewed for the certification period of 11/26/2021 through 1/24/2022. The clinical record failed to contain a plan of care. 4. Clinical record #4 was reviewed for the certification period of 11/13/2021 through 1/11/2022. The clinical record failed to contain skilled nursing visits for 11/16/2021 and 11/23/2021. In addition, the clinical record failed to contain a complete initial comprehensive assessment, care plan and physician orders.

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 clinical record review and staff interviews it was determined the agency failed to send the patient's transfer summary within 2 days of transfer for one (1) of one (1) transferred patient in the survey sample (clinical record #2). The findings were: Clinical record #2 was reviewed for the certification period of 11/04/2021 through 01/02/2021. The electronic clinical record visit schedule indicated a transfer of care on 11/12/2021. The electronic clinical record failed to contain a transfer summary. An interview with employee #2 on 11/29/2021 at 2:55 PM revealed the nurse failed to do a visit note or transfer summary. An interview was conducted with the nurse, employee #3 on 11/30/2021 at 12:56 PM. The nurse presented a composition notebook and stated that is what is used to make notes during nursing visits. The nurse acknowledged failing to document in the electronic record during visits and being behind in entering the documentation into the electronic record at a later date. Employee #3 was able to show some notes for patient #2 in the notebook however, none were for the date of transfer to the hospital.