Every finding on record at Angels Care Home Health of Emerald Coast

During the partial extended recertification survey conducted on 10/24/2022 thru 10/27/2022 at Angels Care Home Health of The Emerald Coast, Emergency Preparedness was reviewed. The home health agency is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A partial extended recertification survey was conducted on 10/24/2022 thru 10/27/2022 at Angels Care Home Health of The Emerald Coast. At the time of the survey, the home health agency was not in compliance with 42 CFR Part 484, Requirements for Home Health Agencies.

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 record review and staff interview, the agency failed to ensure the Condition of Participation for Care Planning, Coordination, Quality of Care requirement was met by failing to develop and update the plan of care to identify patient specific, measurable outcomes and goals, and failed to provide the care in accordance with the written plan of care for 4 of 10 sampled patients, (Patients 1, 5, 8, 9), and failed to notify the physician of changes in needs for 3 or 4 sampled patients (Patients 1, 8, 9). Failure to meet the conditions of Participation for Care Planning, Coordination, Quality of Care places the patient at risk for deterioration in health conditions that may result in a higher level of care. The findings include: The home health agency failed to ensure an individualized plan of care with patient specific, measurable goals for 4 of 10 sampled patients (cross reference G 572). The home health agency failed to ensure care was provided in accordance with the plan of care for 4 of 10 sampled patients (1, 5, 8, 9) (cross reference G572). The home health agency failed to alert Physician for change in needs and outcomes, which were not achieved for 3 of 4 sampled patients (1, 8, 9) (cross reference G572). The cumulative effects of these systemic problems resulted in the facility's inability to furnish care and meet measurable outcomes that the Home Health Agency anticipated that will occur as a result of not coordinating the plan of care as required by the Condition of Participation for Care Planning, Coordination and Quality of Care.

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 record review, patient interviews, staff interviews and policy review, the agency failed to develop and update individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals for 4 of 10 active patient records reviewed, and failed to provide care in accordance with the written plan POC for 4 of 10 sampled patients. (# 1, #5, #8, and #9) The findings include: Patient (Pt) #1 Record review for patient #1 revealed a start of care (SOC) date of 8/24/2021 and a current POC dated 10/18/22 to 12/16/22. A review of the initial SOC Home Health Certification and POC for certification period 8/24/21 to 10/22/21 was conducted. The diagnosis listed on the POC included Major Depressive Disorder, anxiety disorder, hypoglycemia, anorexia, vitamin D deficiency, low back pain, irritable bowel syndrome with diarrhea, hypomagnesemia, osteoporosis, gastro-esophageal reflux disease (GERD), hypokalemia, insomnia, hypothyroidism, chronic kidney disease, history of UTI, body mass index (BMI) 19.9 or less. The POC called for a skilled nurse (SN) frequency of 3 times per week for 2 weeks, then 2 times per week for 7 weeks. Orders were for the psychiatric SN to observe and assess psychiatric status, identify therapeutic communication technique, and intervene to minimize complications. SN to provide skilled teaching and counseling related to psychiatric disease processes, applicable medications and or coping skills, assess vital signs and all body systems, knowledge of disease processes and associated care and medication regimen, evaluate co-morbid and other conditions that present during the episode to identify changes requiring medical attention and intervene to minimize complications. SN to develop a home safety plan and provide education of the importance of use, instruct on effective coping skills to alleviate negative emotions, instruct on methods to improve decision making and problem-solving skills, instruct about generalized anxiety disorder, instruct on fall prevention measures. SN to monitor depression treatment and notify physician if depression symptoms are not adequately controlled by current medication, monitor, and mitigate pain, educate about depression, grief process and sleep patterns. SN to notify physician of vital signs outside of listed parameters. The goals were documented as changes in psychiatric stats will be identified and reported to the physician for prompt intervention. Patient to verbalize appropriate measures to promote safety and prevent injury to self or others and observe/report therapeutic communication techniques by the end of the episode, the patient will have a home safety plan in place within 60 days, will verbalize three effective coping skills to cope with episodes of negative emotions within 9 weeks, will list 3 methods to improve decision making and problem solving skills within 9 weeks, will be able to recognize anxiety and report decrease in anxiety by end of certification period, will have no falls or injuries within 9 weeks, patients depression will be adequately controlled by current medication regimen throughout the certification period as evidenced by no feelings of hopelessness, excessive sleeping or little interest in performing daily activities, pain will be controlled at a comfortable level of A review of the SN visit note dated 10/15/21 revealed the patient had a total score of 4 (severe anxiety) noted as mild severity, on the Hamilton Rating Scale for Anxiety. The Hamilton Rating Scale for Anxiety is a clinical assessment tool used to measure a person's anxiety level by utilizing a psychological questionnaire. The SN documented throughout the note, the patient was experiencing severe anxiety and noted the patient was supposed to go to an estate sale the day of the visit but was unable to go due to family availability to go with the patient. The note revealed the goal of “depression symptoms will be adequately controlled by current medication” was met. A review of the SN Visit note, for skill and recertification, dated 10/22/21 was conducted. The note stated the patient required continued skilled services to assess and educate on anxiety, depression, comorbidities, and medications. The SN narrative note revealed, “mood appears to be good today, and the patient will be going shopping and out to eat with her daughter later in the day”. A review was conducted of the patient medication list which revealed there were no changes in medication during the certification period and the patient did not have antianxiety medications listed on the medication list. Review of the SN notes for the covered period by this POC did not include specific instructions provided to the patient and did not include the patient response to the instructions. The patient was recertified for another 60-day episode of care from 10/23/21 to 12/21/21. A review of the Home Health Certification and POC for 10/23/21 to 12/21/21 was reviewed. There were no new diagnosis noted, and only minor changes were made to the ordered interventions. An order was noted for SN visits 2 times per week for 8 weeks, then 1 time a week for 1 week and an order and modified order for physical therapy (PT) 2 times per week for 2 weeks, then 1 time a week for 2 weeks. A review of the record revealed PT was discontinued effective 11/18/21. The patient goals were carried forward from the previous certification period, with the addition of a goal that the patient will have a decrease in Hamilton Anxiety Scale by the end of the episode”. Review of the SN notes from the previous certification period revealed the patient had a Hamilton Anxiety Scale score indicating mild anxiety. A review of the SN Visit note, for skill and recertification, dated 12/20/21 was conducted. The note revealed the patient reported no pain, skin was intact and there was a low risk of developing a pressure ulcer, had no falls, and was able to independently take the correct medication and proper dosage at the correct time. The Hamilton Rating Scale for Anxiety was documented as 3 and was defined as mild severity and the depression questionnaire was documented as severe depression. The patient was noted to be alert and oriented to person, place and time and was able to follow multi-step commands. The note revealed the patient required recertification due to need for education about coping skills related to high anxiety and was at risk for decompensation and hospitalization. The nurse narrative note stated reinforcement with coping mechanisms would be completed on the next visit so the patient can utilize them through the holiday season. The narrative note revealed the patient was slightly anxious, although the documentation throughout the note was documented as severe anxiety. A review of the medication list revealed the patient did not have any anti-anxiety medication ordered. Review of the SN notes for the covered period by this POC did not include specific instructions provided to the patient and did not include the patient response to the instructions. The patient was recertified for another 60-day episode of care from 12/22/21 to 2/19/22. A review of the Home Health Certification and POC for certification period 12/22/21 to 2/19/22, was conducted which revealed orders for SN visits as 1 time per week for 8 weeks. A review of the intervention orders for the certification period revealed an order for the SN to assess pain, effectiveness of pain management regimen and provide instructions related to pain management, instruct on new and changed medications and reinforce medication, instruct the patient on antidepressant and antianxiety medications. A review of the SN note dated 12/20/21 noted documentation of no pain and a review of the medication list revealed there were no changes in medication since the SOC, and the patient did not have antianxiety, or pain medications listed on the medication list at the time of the assessment. A new order was added to provide skilled teaching related to altered skin integrity The recertification note, OASIS assessment, dated 12/20/21 revealed the patient did not have skin breakdown and was at low risk of skin breakdown. Intervention orders from the previous certification were carried forward. The patient goals were carried forward from the previous certification period with the addition of goals related to pain control measures, understanding of pain medication and goals related to skin integrity and antianxiety medication. The patient OASIS assessment for the recertification dated 12/20/21 revealed the patient had no pain, and review of the medication record at the time of the recertification revealed the patient had no pain or antianxiety medication listed on the medication list. The note further revealed the patient’s skin was intact and the patient had a low risk of skin breakdown. A review of the SN visit note dated 12/27/21 was conducted which revealed no skin breakdown, no pain, the Hamilton Rating Scale for Anxiety revealed a score of 3 which was recorded as mild severity and the depression screen revealed severe depression. The narrative note revealed the patient stated she had a nice Christmas Holiday, and she was feeling okay. The note revealed the patient now understands all aspects of antidepressant medication, can implement methods to make better decisions and solve problems and the goal of verbalize stages of grief and acceptance of own grieving processes was met. A review of the SN Visit note, for skill and recertification, dated 2/16/22 continued to note the patient reported no pain, the Hamilton Rating Scale for Anxiety was documented as mild severity and the depression screening showed severe depression. The note revealed the SN is required for evaluation of medication management as well as assistance in identification and implementation on non-pharmacological coping mechanisms. The note revealed the homebound status as the patient becomes extremely overwhelmed and agitated when outside of the home for greater than an hour at a time. She becomes increasingly agitated in high stimulation environments such as shopping at Walmart, going to a crowded church and traffic jams. Review of the SN notes for the covered period by this POC did not include specific instructions provided to the patient and did not include the patient response to the instructions. The patient was recertified for another 60-day episode of care from 2/20/22 to 4/20/22. A review of the Home Health Certification and POC dated 2/20/22 to 4/20/22, was conducted which revealed an order for SN 1 time per week for 9 weeks. The POC intervention orders were carried forward from the last certification period with two interventions added of SN to provide instruction regarding management of disease process related to chronic kidney disease (CKD) pathophysiology, nutritional/fluid requirements and medication regimen and the SN to weigh the patient every visit and to notify the physician of weight loss of 2 pounds in 1 week. The diagnosis of CKD was on the diagnosis list at the time of admission. A review of the goals revealed all goals related to skin and pain were removed and a goal of genitourinary system was added which stated, genitourinary system will be evaluated, and interventions implemented to minimize complications, and the patient’s weight would remain within the parameters indicated. There were no medication changes. A review of the SN Visit note, for skill and recertification, dated 4/20/22 revealed the primary reason for home health services was for anxiety disorder. The Hamilton Rating Scale for Anxiety revealed the patient was scored as mild severity of anxiety. The medical rational for continued skilled services was documented as necessary for medication management and for treatment and evaluation of generalized anxiety disorder. The note revealed the patient had no cognitive impairment and lives with other family members. A review of the medication record revealed Ibuprofen was added to the medication list, there were no other new medications, and no medication changes were made during the certification period. There was no antianxiety medication listed on the patient medication list. A review of the vital signs report for the certification period revealed the patient weight was obtained 2 out of the 9 completed visits on 3/1/22 and 4/4/22. The record gives no indication of why the POC was not fully implemented, nor that the physician was notified that it was not fully implemented. The patient was recertified for another 60-day episode of care from 4/21/22 to 6/19/22. A review of the Home Health Certification and POC for certification period 4/21/22 to 6/19/22 revealed an order for SN visits 1 time per week for 8 weeks. The intervention orders were carried forward from the previous certification period with the additional intervention to instruct on a healthy diet and panic attacks. A review of the medication list revealed an addition of antianxiety medication with a date of 6/1/21. A review of the patient goals revealed goals added included the patient will have a home safety plan in place within 60 days, which was on the SOC POC, and the goal had previously been met and a goal of 100% understanding of how stigma relates to mental health was added which was previously marked as met. A new goal related to a healthy, balanced diet was added. All other goals from the previous certification period were carried forward. A review of the SN Visit note, for skill and recertification, dated 6/15/22 revealed the Hamilton Anxiety Scale was documented as mild severity and the depression screening was documented as severe depression. The rationale for continued skilled services was documented as visits are needed for medication management and for treatment and evaluation of severe anxiety. A review of the medication list revealed an antianxiety medication was added, but no other medications were added during the certification period. There was no documentation of the patient response to the teaching provided. The patient was recertified for another 60-day episode of care from 6/20/22 to 8/18/22. A review of the Home Health Certification and POC for certification period 6/20/22 to 8/18/22 was reviewed. The diagnosis list included diagnosis of hypokalemia and hypothyroidism which was on the SOC POC, then later removed. Orders for SN 1 time per week for 9 weeks and all interventions were carried forward from the previous certification period. The goal patient will verbalize 100% understanding of how stigma related to mental health can be a barrier to mental health treatment was added, which was previously documented as met, and a goal, patient will verbalize 100% understanding of depression instruction was added. The goal did not delineate the topics of the education that would be taught. A review of the SN visit note dated 8/15/22 revealed a Hamilton Anxiety Scale score of 3 and was documented as mild severity. The medical rationale for skilled services was documented as visits are required for medication management and for treatment and evaluation of severe anxiety. The note revealed the patient homebound status due to the patient must wait for a caregiver to become available prior to leaving the home. This is quite an inconvenience to her friends and family. The patient was recertified for another 60-day episode of care from 8/19/22 to 10/17/22. A review of the Home Health Certification and POC for certification period dated 8/19/22 to 10/17/22 was conducted. Order for SN 1 time per week for 9 weeks. The intervention orders included an intervention for skilled teaching related to altered skin integrity, which was on a previous POC and was subsequently removed. The recertification note dated 8/15/22 revealed no skin breakdown. An intervention for instruction on antipsychotic medication was added. Review of the medication list revealed the patient has been on the same antipsychotic medication and the same dose since the SOC, and there have been no changes made. A new intervention to monitor sleep was added, which was on a previous POC and was documented as goal met. All other interventions and goals were carried forward. There were no medication changes noted. A review of the SN Visit note, for skill and recertification, dated 10/17/22 revealed the patient’s skin was intact, the Hamilton Anxiety Scale continued to document mild anxiety. The SN documentation revealed the need for continued skilled care was for education on disease process and medications. The homebound status was documented as appointments must be made in advance and the patient must wait for a caregiver to become available. The patient was recertified for another 60-day episode of care from 10/18/22 to 12/16/22. A review of the Home Health Certification and POC for certification dated 10/18/22 to 12/16/22 revealed SN ordered for 1 time per week for 8 weeks. There were no changes in the diagnosis documented and no intervention changes and no medication changes. There were no changes to the patient's goals. Subsequent POC’s from 12/22/21 to the current certification period indicate very little, if no change in diagnosis or SN interventions and no change in SN frequency. SN progress notes do not indicate a deficit in the patient/caregiver’s ability to comprehend teaching which may necessitate the need for repetitive teaching. Throughout the certification periods, there was little documentation of the information taught to the patient and no documentation of the patient response to the teaching. The record indicates no communication with the physician or the patient mental health provider during these multiple certification periods (other than a communication note at the end of each period listing reasons for requesting continued certification orders) to inform him/her of the patients documented “extreme anxiety”, failure to obtain weights, or inability to meet the patient’s established goals. There is no evidence the agency made any attempts to increase SN visit frequency or to provide greater nursing support and education and referrals to help the patient meet goals during these periods. It appears the agency chose to minimally address various diagnoses during each certification period and not address others at all. Interventions of pain management and skin integrity were added to the POC, although the assessment indicated that the patient did not have pain, there was no pain medication noted on the medication list until 3/3/22 at which time Ibuprofen was added, and antianxiety medication was not added until 6/1/22 and the skin was consistently documented as intact. Interview with the case manager, Staff G on 10/27/22 at 10:27 AM, revealed when asked how often he addresses the interventions on the POC, stated you have to addresses what is in front of you, and stated he goes “on the fly” and will go back to the planned interventions later if he has time. Staff G stated the patient has a primary care physician and a therapist that she sees via telehealth and then stated, “telehealth is not part of this agency”. Staff G stated the patient will be discharged when psychiatric symptoms are managed with current treatment, the functional abilities are acceptable, and the patient is overall stable. Pt #9 Review of Patient #9 record revealed a SOC date of 11/20/21 and a current certification period of 9/16/22 to 11/14/22. A review of the SOC Home Health Certification and POC for certification period 11/20/21 to 1/18/22 revealed orders for SN 1 time per week for 10 weeks and Physical Therapy (PT) 2 times per week for 3 weeks then 1 time per week for 2 weeks. PT was discontinued on 12/27/21 per the patient request, due to increased pain with physical therapy. The SN interventions ordered were instruct on management of hypertension, assessment of pain and effectiveness of pain management, instruct on new medications, instruct on skin integrity, perform fall risk assessment and implement interventions to reduce falls, assess vital signs and body systems and intervene to minimize complications, instruct related to cardiovascular status, instruct on pain relief measures, rheumatoid arthritis, fibromyalgia and report vital signs outside the provided parameter. The patient goals were documented as, will verbalize/demonstrate ability to care for hypertension by end of episode, verbalize understanding of pharmacologic and non-pharmacologic pain control measures within 30 days, will increase understanding of medications as evidenced by recall of purpose, action, and side effects within 9 weeks, changes in skin integrity status will be identified and reported and prompt interventions will be put in place by end of episode. Patient will demonstrate/verbalize knowledge of interventions to prevent falls and safety hazards within 30 days, will remain safe within home environment as evidenced by no falls or injuries throughout episode, cardiovascular exacerbations will be identified promptly and interventions initiated to minimize associated risk, will verbalize/demonstrate an ability to care for altered cardiovascular status by the end of the episode, pain will be controlled and managed at the patient’s own comfort level as verbalized by the patient within 9 weeks, will verbalize 100% understanding of rheumatoid arthritis within 9 weeks, will verbalize 100% understanding of fibromyalgia within 9 weeks. A review of the SN Visit note, for skill and recertification, dated 1/18/22 revealed the need for recertification as assessment and education regarding managing chronic pain and then stated the patient continues to manage her pain with rest, but reports scheduled knee replacement surgery on 2/3/22. A review of the patient’s medication list revealed the patient did not have pain medication listed. The patient was recertified for another 60-day episode dated 1/19/22 to 3/19/22. A review of the Home Health Certification and POC for certification dated 1/19/22 to 3/19/22 was completed. Orders for SN 1 time per week for 8 weeks and PT 1 time per week for 1 week and 3 times per week for 2 weeks. All other interventions remained the same with minor changes, and goals remained the same with minor changes. A review of the SN Visit note, for skill and recertification, dated 3/18/22 was conducted. The patient pain level was noted to be a level of 8 in the right knee. The need for continued skilled services was documented as the patient requires continued skilled assessment and education regarding chronic pain and managing knee replacement, safety measures and medication management and noted the patient understands symptoms of infection and edema management at the incision site. The note revealed the patient hypertension was controlled with the current regimen. The patient was recertified for another 60-day episode dated 3/20/22 to 5/18/22. A review of the Home Health Certification and POC for certification period dated 3/20/22 to 5/18/22 revealed orders for SN 1 time per week for 9 weeks and PT 2 times per week for 4 weeks. The intervention orders remained the same with the addition of instruct on risks associated with total knee replacement and methods to enhance recovery and instruct patient on the signs and symptoms of depression and methods to cope with depression. The goals were carried forward with the addition of a goal the patient will verbalize 3 signs and symptoms of depression and 3 methods to cope with depression within 9 weeks, will be able to name 3 risks associated with total knee replacement within 9 weeks, will verbalize 100% understanding of methods to enhance knee replacement recovery as evidenced by compliance with medication and PT regimen. A review of the SN Visit note, for skill and recertification, dated 5/18/22 revealed the patient’s pain level remains at a stated level of 4 all the time and pain level at the time of the assessment was documented as 7 on a 0-10 pain scale. The note stated continued skilled services were needed for assessment and education regarding chronic pain, anxiety, and caregiver stress. PT was discontinued per the patient request. The patient was recertified for another 60-day episode dated 5/19/22 to 7/17/22. A review of the Home Health Certification and POC for certification dated 5/19/22 to 7/17/22 SN orders continued as 1 time per week for 8 weeks. The interventions had only minor changes with the addition to teach on “over the counter” pain medications, and opioid pain medications. A review of the patient medication list for the certification period revealed there were no over the counter or opioid pain medications listed on the medication list. The goals were carried forward with only minor changes, to include instructing on adjunctive medications. The notes revealed the patient can comprehend instruction and the patient’s cognitive status is documented as intact. A review of the SN Visit note, for skill and recertification, dated 7/15/22 revealed continued documentation of pain level at a level of 4 all the time and pain at the time of the assessment was documented as a level of 7 on a pain scale of 0-10. The continued need for skilled services was documented as assessment and education regarding hypertension, chronic pain and increased anxiety. The homebound status was documented as the patient requires frequent rest periods after 5 minutes of activity due to decreased endurance and to control pain and shortness of breath. The patient was certified for another 60-day episode. A review of the Home Health Certification and POC for certification dated 7/18/22 to 9/15/22 was completed. The SN orders continued as 1 time per week for 8 weeks. The intervention orders and goals remained the same with only minor changes to the instruction provided. A review of the SN Visit note, for skill and recertification, dated 9/14/22 revealed continued documentation of pain level of 4 all the time and pain at the time of the assessment was documented as a level of 8 on a pain scale of 0-10. The note revealed continued skilled care was needed for education on hypertension and anxiety and further documented throughout the episode the patient’s blood pressure has been managed with only a few reports of elevation. The patient was certified for another 60-day episode. A review of the Home Health Certification and POC for certification period dated 9/16/22 to 11/14/22 was conducted. Orders for SN 1 time per week for 8 weeks and all goals and interventions were carried forward with only minor changes. Subsequent POC’s from 1/18/22 to the current certification period indicate very little, if no change in diagnosis or SN interventions and no change in SN frequency. SN progress notes do not indicate a deficit in the patient ability to comprehend teaching which may necessitate the need for repetitive teaching. Throughout the certification periods, there was little documentation of the information taught to the patient and no documentation of the patient response to the teaching. The record indicates no communication with the physician during these multiple certification periods (other than a communication note at the end of each period listing reasons for requesting continued certification orders) to inform him/her of inability to meet the patient’s established goals. There is no evidence the agency made any attempts to increase SN visit frequency or to provide greater nursing support and education and referrals to help the patient meet goals during these periods. It appears the agency chose to minimally address various diagnoses during each certification period and not address others at all. On 10/27/22 at approximately 1:19 PM, an Interview was conducted with patient #1 who confirmed that she receives services from the agency and stated the nurse does vital signs during the visit, and then sees her husband. The patient stated she doesn’t want to sit around and get lazy, and stated she tries to get up and run around town, and stated she goes to her girlfriends, they go to lunch and the movies and visit friends. Pt #8 Review of Patient #8 record revealed a SOC date of 7/17/21 and a current certification period of 9/10/22 to 11/8/22. A review of the SOC Home Health Certification and POC dated 7/17/21 to 9/14/21 revealed orders for SN 1 time per week for 10 weeks and PT effective 10/18/21 which was discontinued on 8/25/21 due to patient #8 meeting PT goals. The diagnosis listed on the POC are documented as Type 2 diabetes, atherosclerosis arteries of extremities on both legs, hypertension, atrial fibrillation, mild cognitive impairment (so stated), COPD (Chronic Obstructive Pulmonary Disease), osteoarthritis, dissection of abdominal aorta, nicotine dependence, long term use of oral hypoglycemic drugs, long term use of aspirin. The ordered interventions were documented as SN to teach on management of hypertension, changes in medications, assess vital signs and all body systems and patient knowledge of disease process and associated care and medication regimen, evaluate and intervene in co-morbid disease processes to minimize complications, instruct on pathophysiology of diabetes mellitus, importance of maintaining blood sugar levels, signs and symptoms of hypoglycemia and hyperglycemia, importance of exercise and activity with diabetes, signs and symptoms of cardiovascular disease, infection control measures, assess lower extremities for the presences of skin lesions and instruct on proper foot care, fall prevention measures, monitor and mitigate pain, instruct on measures to prevent pressure ulcers, causes of high blood pressure, on abnormal blood pressure readings, symptoms of Atrial-Fibrillation, methods to detect and manage edema, on peripheral vascular disease, training on claudication, risks for peripheral vascular disease, symptoms of peripheral vascular disease, lifestyle changes needed with peripheral vascular disease, treatment of peripheral vascular disease, notify physician of vital signs outside of listed parameters. Goals were documented as patient/caregiver will verbalize/demonstrate ability to care for hypertension by the end of the episode, increase understanding of medications as evidenced by recall of purpose, action and side effects within 9 weeks, verbalize 100% understanding of pathophysiology of diabetes mellitus within 60 days, verbalize 100% understanding of importance of maintaining normal blood sugar levels within 30 days, name 3 signs and symptoms of hypo and hyper glycemia within 30 days, verbalize 100% understanding of ways to safely exercise within 60 days, name 3 signs and symptoms of cardiovascular disease within 9 weeks, verbalize 100% understanding of infection control measures within 30 days, verbalize 100% understanding of proper foot care within 9 weeks, will have no falls within 9 weeks, pain will be controlled at a level of period, skin will remain intact throughout the certification period, verbalizes 100% understanding of causes of hypertension, within 9 weeks, verbalize normal and abnormal blood pressure readings within 9 weeks, verbalize 3 signs and symptoms of atrial fibrillation within 9 weeks, verbalize 100% understanding on how to detect and alleviate edema within 9 weeks, verbalize 100% understanding of Peripheral Vascular Disease within 9 weeks, verbalize 100% understanding of complications of untreated peripheral vascular disease within 9 weeks, verbalize 100% understanding of lifestyle changes needed with peripheral vascular disease within 9 weeks, verbalize 100% understanding of treatment of peripheral vascular disease within 9 weeks. A review of the SN Visit note, for skill and recertification, dated 9/14/22 was completed. The SN assessment revealed the medical rationale for continued skilled services was documented as the patient/caregiver requires continued assessment and education regarding cognitive impairment and memory loss and the patient has been maintaining blood sugar throughout the certification period. The note revealed the patient’s caregiver reported the patient had become more lethargic and his cognitive impairment was worse and noted the caregiver is not providing an ordered medication because it caused the patient to sleep too much. There was no documentation of patient/caregiver understanding of information taught and there was no documentation of physician notification of the worsening cognitive functioning, increased lethargy or the caregiver concern related to the medication. The patient was certified for another 60-day episode. A review of the Home Health Certification and POC for certification period dated 9/15/21 to 11/13/21 revealed orders for SN 1 time per week for 8 weeks and PT evaluation. New interventions were added related to neurological system education, assessments and interventions, instruct on nutrition and hydration, new medication, instruct on complications of diabetes and instruct on maintaining blood sugar readings. Goals related to the new interventions were added including verbalize 100% understanding of importance of maintain normal blood sugar levels within 30 days, verbalize 100% understanding of proper foot care within 9 weeks, verbalize 100% understanding on how to detect and alleviate edema within 9 weeks, verbalize 100% understanding of claudication within 9 weeks. Review of SN recertification visit note dated 11/10/21 noted continued skilled care was needed for assessment and education regarding cognitive impairment, wound care and fall precautions, PT to continue plan of care. There was no documentation on the response to the teaching from the patient or the patient caregiver throughout the certification period. A review of the Home Health Certification and POC for certification period dated 11/14/21 to 1/12/22 revealed an order for SN 2 times per week for 3 weeks and 1 time per week for 6 weeks and PT to continue POC and re-evaluate the week of 11/14/21. New intervention orders include wound care to the arms twice weekly, may discontinue when wound is healed. The interventions were carried forward and goals of 100% understanding of infection control measures within 30 days, 100% understanding of foot care within 9 weeks and 100% understanding on how to detect and alleviate edema within 9 weeks and 100% understanding of claudication within 9 weeks carried forward. Review of the SN recertification visit note dated 1/11/22 revealed continued skilled services were needed for continued assessment and education regarding managing safety measures and cognitive impairment. There was no documentation on the response to the teaching from the patient or the patient caregiver throughout the certification period. The patient was recertified for another 60-day episode. A review of the Home Health Certification and POC for period dated 1/13/22 to 3/13/22 revealed orders for SN 1 time per week for 8 weeks, and PT 1 time per week for 1 week. A new order for SN to assess patient with Alzheimer's disease and instruct family/caregivers in proper management techniques of the patient with Alzheimer's and behavioral disturbances associated with the disease was added. A review of the documented diagnosis list noted the patient with mild cognitive impairment, so stated. Interventions and goals were established related to the diagnosis of Alzheimer's disease. A review of the SN recertification visit note dated 3/9/22 was conducted. Skin was documented as intact, and Diabetes was documented as controlled with the current regimen. The note revealed need for continued skilled care was for assessment and education regarding managing cognitive impairment, confusion, safety precaution and medication management. There was no documentation of patient/caregiver understanding of the teaching provided. A review of Home Health Certification and POC dated 3/14/22 to 5/12/22 revealed orders for SN 1 time per week for 9 weeks and PT to continue with the POC. The POC included interventions for SN to instruct/reinforce diabetic foot care, assess and teach related to altered skin care, although skin was noted as intact on the recertification note dated 3/9/22. Goals included 100% understanding of diabetic diet and demonstrate how to perform a Blood Glucose test, 100% understanding of ways to safely exercise within 60 days, 100% understanding of symptoms and methods to cope with sundowning, 100 % understanding of the anatomy of the urinary tract within 9 weeks, 100% understanding of treatment and prevention of UTI (Urinary Tract Infection) within 9 weeks, 100% understanding how to detect and alleviate edema within 9 weeks and 100% understanding of instruction of dementia behaviors within 9 weeks; there was no diagnosis of dementia listed on the diagnosis list. A review of the SN recertification visit note dated 5/11/22 was conducted. The need for continued skilled care was documented as continued assessment and education regarding cognitive deficits, managing behaviors, communicating and fall precautions. Review of notes throughout the certification period revealed no documentation of the effectiveness of the education provided. A review of the Home Health Certification and POC dated 5/13/22 to 7/11/22 revealed an order for SN 1 time per week for 8 weeks, PT 1 time per week for 1 week, and ST 1 time per week for 1 week. PT was discontinued on 6/7/22 due to a plateau in progress and ST evaluation determined patient is not a candidate. The interventions continue to include SN teaching related to altered skin integrity in spite of documenting skin is intact. Goals include 100% understanding of diabetic diet, demonstrate how to perform blood glucose monitoring (spouse is reporting results to nurse), goal related to pain management, although pain documented as 0 during recert visit and a 2 less often than daily. Goals related to skin integrity, although skin was documented as intact. A goal of verbalize 100% understanding of dementia within 9 weeks, 100% understanding of effective strategies for interacting with the Alzheimer’s patient within 60 days, verbalize 100% understanding of ways to safely exercise within 60 days, verbalize 100% understanding of instruction of dementia behaviors within 9 weeks are included on the POC. A review of the SN recertification visit note dated 7/9/22 revealed the patient/caregiver need more assessment and education regarding dementia and behavior. There was no documentation of response to the education provided, there was no documentation if a Home Health Aide or other referrals were made for the documented caregiver stress and there was no documentation of the patient/caregiver response to the provided teaching. A review of the Home Health Certification and POC dated 7/12/22 to 9/9/22 revealed an order for SN 1 time per week for 9 weeks. Continues to order teaching related to skin integrity and pain control instruction. The goals include verbalize 100% understanding of infection control measures within 30 days, verbalize 100% understanding of proper foot care within 9 weeks, 100% understanding of dementia behaviors within 9 weeks. A review of the SN recertification visit note dated 9/7/22 continued to document no pain and skin was intact. The note revealed the need for continued skilled care was needed for assessment and education regarding managing dementia and medications. There was no documentation throughout the certification period to the patient/caregiver response to the provided teaching. A review of the Home Health Certification and POC dated 9/10/22 to 11/8/22 revealed an order for SN 1 time per week for 9 weeks. Interventions continue to include pain related interventions although pain continues to be documented as 0 and instructions on preventing pressure ulcers continues, despite continued documentation that skin was intact. Goal continues that caregiver will verbalize 100% understanding of proper foot care within 9 weeks. There was no documentation throughout the certification period to the patient/caregiver response to the provided teaching. Pt 5 Review of Patient #5 record revealed a SOC date of 1/21/21 and a current certification period of 9/13/22 to 11/11/22. A review of the SOC certification dated 1/21/22 to 3/21/21 revealed SN ordered 1 time per week for 1 week, 2 times a week for 1 week and 1 time a week for 1 week, PT 1 time per week for 1 week, OT (Occupational Therapy) 1 time per week for 1 week, Medical Social Worker (MSW) 1 time per week for 1 week. The diagnosis listed on the POC include Anemia, acute gastritis with bleeding, heart and chronic kidney disease, type 2 diabetes, chronic obstructive pulmonary disease, (COPD), atrioventricular block, gout, dementia, Atrial Fibrillation, osteoarthritis, and pacemaker. Intervention orders include SN for instructions/reinforcement of diabetic care to include diet, skin care, blood glucose testing and diabetic foot care, teaching/reinforcement of hypertension, assess and intervene gastrointestinal (GI) system to minimize complications, provide teaching related to GI status, pathophysiology, nutritional requirements and medication regimen, educate on new and changed medications and may reinforce medication instruction related to the use of medications to treat disease processes. SN to fill Medi planner (Pill organization box) every week, assess vital signs and all body systems, knowledge of disease process and associated care and medication regimen, evaluate co-morbid and other conditions that present during the episode and intervene, instruct on anemia types, causes, signs and symptoms and treatment, instruct on foods high in iron, energy conserving techniques, infection precautions, will assess lower extremities for the presence of skin lesions and instruct on proper foot care, instruct on fall prevention, monitor and mitigate pain, instruct patient to notify physician if weight gain >3 pounds in 24 hours, methods to detect and manage edema, instruct on pacemaker safety measures, parameters set for notifying MD (Medical Doctor) of vital signs. Goals include patient will verbalize 100% understanding of the types and causes of anemia within 9 weeks, understand 100% understanding of the treatment of anemia within 9 weeks, understand 100% of the treatment of anemia within 9 weeks, 100% understanding of infection control measures within 30 days, 100% understanding on how to detect and alleviate edema within 9 weeks, 100% understanding of importance to monitor blood sugar readings for symptoms of hypo and hyper glycemia within 9 weeks, verbalize 100% understanding of pacemaker safety measures within 9 weeks. A review of the SN recertification visit note dated 3/17/21 revealed the need for recertification was documented as continued assessment and education regarding Congestive Heart Failure (CHF), CKD and managing edema, assistance with filling her own medication box. Review of documentation through the certification period revealed little documentation on the patient’s response to the education provided. A review of the Home Health Certification and POC dated 3/22/21 to 5/20/21 revealed orders for SN 1 time per week for 9 weeks. Goals included 100% understanding of proper foot care within 9 weeks, verbalize 100% understanding of signs and symptoms of heart failure to report within 2 eeks, 100% understanding of chronic kidney disease within 9 weeks, 100% understanding of risk factors for kidney disease within 9 weeks, 100% understanding of how to detect and alleviate edema within 9 weeks, 100% understanding of pacemaker safety measures within 9 weeks. A review of the SN recertification visit note dated 5/17/21 revealed continued skilled care needed for assessment and education regarding indigestion and dietary choices to help reduce heartburn. The note revealed the nurse would start teaching the resident how to set up her medication on the next visit. A review of the Home Health Certification and POC dated 5/21/21 to 7/19/21 revealed an order for SN 1 time per week for 8 weeks. An intervention order to instruct on GI (gastrointestinal) status was added. The intervention was on the initial POC. The interventions from the previous certification were carried forward. Goals included 100% understanding of essential vitamins and minerals and dietary supplements 100% understanding of proper foot care, 100% understanding of how the kidney function within 9 weeks, 100% understanding of chronic kidney disease within 9 weeks, 100% understanding of risk factors for kidney disease within 9 weeks, 100% understanding of how to detect and alleviate edema within 9 weeks. A review of the SN recertification visit note dated 7/15/21 revealed the patient needs continued assessment and education regarding GERD (Gastroesophageal reflux disease) symptoms and proper diet, patient also needs assistance with setup up Guardian pharmacy for her medications due to not being able to fill med box herself. A review of documentation for the certification period revealed no referrals to the registered dietician, no calls to the physician related to the GERD symptoms, and little to no documentation on the patients understanding to the education provided. A review of the home health Certification and POC dated 7/20/21 to 9/17/21 revealed no changes in the frequency of SN visits, diagnosis or interventions. The goals remain the same and continue to show 100% understanding of foot care within 9 weeks, 100% understanding of how to alleviate edema within 9 weeks and 100% understanding of pacemaker safety within 9 weeks. A review of the SN recertification visit note dated 9/16/21 revealed the nurse continues to set up medication continued skilled care was needed to assist and educate the patient on medication management. No interventions were documented on the visit note, there was no documentation throughout the certification period on the patients understanding to the education provided. A review of the Home Health Certification and POC dated 9/18/21 to 11/16/21 revealed orders for SN 1 time per week for 9 weeks, there were minimal changes to interventions with goals to include 100% understanding of diabetic diet, 100% understanding of proper foot care within 9 weeks, 100% understanding of how to detect and alleviate edema within 9 weeks, 100% understanding of pacemaker safety and measures within 9 weeks, interventions for pain management added. A review of the SN recertification visit note dated 11/15/21 revealed need for continued skilled care for education regarding alternate methods for pain control, continued education regarding hypertension, CHF, CKD, diabetes and medication management. The note revealed the patient continued to need assistance filling her medication box and the patient could not afford a pre-packaged service. There was no documentation throughout the certification period of referrals made to the social worker for community resources, or on the patients understanding of the instructions provided. A review of the Home Health Certification and POC dated 11/17/21 to 1/15/22 revealed an order for SN 1 time per week for 8 weeks. There were minimal changes made on the interventions and goals continue to note 100% understanding of infection control measures within 30 days, 100 % understanding of proper foot care within 9 weeks, 100 % understanding of how to detect and alleviate edema within 9 weeks. A review of the SN recertification visit note dated 1/13/22 revealed the patient did not have one of her medications for diabetes management due to inability to afford the medication and noted the patient needs to be set up with a pre-packaged medication company. The note revealed the SN called the physician for orders for the recertification, but there was no documentation the physician was notified of the patient's inability to obtain the medication. There was no documentation that a referral was made to the social worker to assist the resident obtain community resources. The note documented the need for continued skilled services for education regarding GERD and medication management. There was no documentation throughout the certification period of the patients understanding of the instructions provided. A review of the Home Health Certification and POC dated 1/16/22 to 3/16/22 SN revealed an order for SN 1 time per week for 9 weeks. There were minimal changes to the interventions and goals. The POC continues to reflect goals to verbalize 100% understanding of infection control measures within 30 days, 100% understanding of proper foot care within 9 weeks. A review of the SN recertification visit note dated 3/14/22 revealed no changes in the SN frequency. The note revealed the patient needs continued skilled assessment and education regarding medication oversight and compliance and management of GERD. The note revealed the patient was filling her own medication box with minimal mistakes. Review of the notes revealed no documentation on patients’ response to the teaching. A review of the Home Health Certification and POC dated 3/17/22 to 5/15/22 revealed orders for SN 1 time per week for 8 weeks, and minimal changes on ordered interventions. The goals carried forward with the goals 100% understanding of diabetic diet and 100% understanding of how to detect and alleviate edema within 9 weeks continuing. A review of the SN recertification visit note dated 5/11/22 revealed a need for continued skilled services for assessment and education regarding increased arthritis pain, chronic sinusitis and medication oversight. There was no documentation of the patients understanding of the provided education throughout the certification period. A review of the Home Health Certification and POC dated 5/16/22 to 7/14/22 revealed order for SN 1 time per week for 9 weeks with interventions related to pain added. Goals continue with 100% understanding of diabetic diet, 100% understanding of osteoarthritis within 9 weeks, 100% understanding of proper foot care in 9 weeks. A review of the SN recertification visit note dated 7/12/22 revealed continued skilled services needed to assess medication efficacy and management of new diagnosis of rheumatoid arthritis. There was no documentation of response to teaching throughout the certification period. A review of the Home Health Certification and POC dated 7/15/22 to 9/12/22 revealed no changes in the SN frequency, minimal changes to the ordered interventions and goals continue to include verbalize 100% understanding of Rheumatoid arthritis within 9 weeks, 100% infection control measures, 100% proper foot care, 100% detect and alleviate edema within 9 weeks, 100% understanding of importance of monitor blood sugar reading within 9 weeks, 100% pacemaker safety measures within 9 weeks. A review of the SN recertification visit note dated 9/9/22 revealed need for continued skilled services for education on disease process: COPD exacerbation. A review of the Home Health Certification and POC dated 9/13/22 to 11/11/22 revealed no changes in SN frequency, minimal changes in interventions and goals include 100% understanding of Cardiac balanced nutrition and importance of adherence to diet within 30 days, 100% pathophysiology, causes and progressive course of COPD, 100% understanding of signs and symptoms of COPD and what to report, 100 % understanding of proper foot care, 100% understanding of how to alleviate edema within 9 weeks. On 10/26/22 at 9:15 AM, an interview was conducted with Staff H, Registered Nurse (RN) who stated the POC is developed on admission based on the patient’s diagnosis and medications. Staff H stated there are pathways that are selected, and the pathway pre-populates the interventions and stated the nurse would make a note if the intervention is not needed. Staff H stated a patient will be discharged if they meet the goals, are stable and stated they can be discharged if they haven’t met their goals if the patient is stable. On 10/26/22 at approximately 2:24 PM, an interview was conducted with the agency’s Director of Nurses, (DON) who stated the admission nurse develops the initial POC based on diagnosis and medication and patient needs. She stated the nurse uses pathways for diagnosis and medications and the nurse can then pre-plot the interventions and stated the nurses can document the intervention is not applicable. She stated she expects the nurses to follow or address the interventions that are documented on the POC and stated when a patient is recertified, the nurse must mark the goals that are already met so they will not carry over. She stated they try to find something different for each certification period to focus on and stated they could increase SN visits if needed. She stated a patient is discharged when goals are met and confirmed goals that require 100% understanding is not a reasonable and attainable goal and confirmed the nurse should document the specific education provided and the patients response to the education, and goals should be marked complete when the patient meets the stated goal. A follow-up interview was conducted on 10/27/22 at approximately 2:21 PM, with the DON who stated homebound status means it is a taxing effort to leave home, there is a barrier to getting the patient out of the house and stated outings should be infrequent. Review of policy, “Plan of Care” HH5-2A.01, effective 7/1/2018, last revised on 2/22 revealed the POC is based upon relevant assessment findings and the findings are used to identify the patient’s problems and their ability to respond to interventions, and to develop realistic and achievable goals. If the physician orders cannot be completed the physician is consulted to approve additions or modifications to the original plan.

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 record review, the home health agency failed to ensure the duration of visits to be made for 1 of 13 sampled patients (#6). The findings include: A review of sampled patient #6’s medical record, revealed a Client Coordination Note Report dated 9/27/2022 with an amendment to the plan of care to include a home health aide one time a week. The home health agency failed to reveal the duration of the visits to be made. An interview was conducted with the Director of Nurse (DON) at approximately 1:55 PM, on October 26, 2022. The DON confirmed there was no duration on the order for the home health aide.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and record review, the home health agency failed to provide the documented evidence and an operational demonstration that they had developed, implement, evaluated, and maintained an effective, ongoing, agency-wide, data-driven quality assurance performance improvement (QAPI) program. The findings include: Cross Reference G642. Based on interview and record review, the home health agency failed to provide documented evidence of an ongoing QAPI program that would measure, analyze, track quality indicators, adverse patient events, complaints, and other aspects of performance that enable the agency to assess process of care, services, and operations.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, review of the facility's Agency Patient-Related Characteristics (Case Mix) report and review of the facility's Quality Assessment Performance Improvement (QAPI) plan, the facility failed to identify an opportunity to improve patient health outcomes by recognizing trends in the patient’s extended length of stay, and failed to identify concerns with the documentation in the patient’s medical record during chart audits. Patient safety and quality of care has the potential to affect all patients. The findings include: Review of the Agency Patient-Related Characteristics (Case Mix) report revealed the home health agency Length of stay until discharge for the period dated 8/21 to 7/22 was 122.79 days. The prior observation period was 115.54 days. The national average for patient length of stay was reported as 57.8 days. The agency length of stay for a patient from 1-30 days was noted to be 27.29%, and the prior observation period was 23.94%. The national average was noted to be 43.78%. The agency length of the stay from 31-60 days was 18.33%. The prior observation period was 25.35% and the national average was noted to be 36.44%. The agency length of stay from 61-120 days was 18.33%, the prior observation period was 27.04% and the national average was noted to be 12.26%. The agency length of stay for 121 to 180 days was noted to be 9.96%, the prior observation period was 8.73% and the national average was noted to be 3.44%. The agency length of stay for more than 180 days was not to be 20.32%, the prior observation period was 14.93%, and the national average was noted to be 4.08%. On 10/27/22 at approximately 2:29 PM, an interview was conducted with the Director of Nurses, (DON) who confirmed she has oversite of the QAPI program, and stated QAPI meeting discussions are based on a structured agenda where infections, star ratings and Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS), results, occurrences and the avoidable events report are discussed. She confirmed the patient length of stay was long and confirmed there was no active plan of correction in place at the time of the survey. She confirmed when she identifies a problem with a record, she will address the concern with the nurse and confirmed she does not track or trend or analyze the data to identify patterns or trends. During the interview the Administrator confirmed the length of stay was above the national average, and stated, “it has come down”, but could not identify any steps that have been put into place to track, trend, or analyze the data to improve outcomes. During an interview with the DON on 10/26/22 at approximately 2:24 PM, she revealed she completes chart audits quarterly, and during the interview confirmed a patient outcome goal that indicates a patient will have 100% understanding of the material taught is not a reasonable goal, and confirmed the nurses should be documenting the specific information that is taught and the patient response to the teaching provided, and the goals should be marked complete when the patient reaches the goal. Record reviews during the survey revealed little to no documentation of the specific information taught, patient response to the education, failure to notify the physician, and multiple goals requiring the patient to have 100% understanding of the information were found, (cross reference G572), and all of the discharged records reviewed failed to have a discharge summary (cross reference G1022). Review of the agency’s policy titled “Quality Assessment Performance Improvement program", effective 7/1/18, last revised August 2022 states under Guidelines/Procedures: "Agency will strive to improve operational and patient health outcomes by implementing a performance improvement plan that incorporates monitoring performance through data collection, analyzing current performance and improving and sustaining improved performance." Clinical Record Review: Clinical record review is a method of systematic evaluation of the documentation in the clinical record conducted in accordance with state and federal regulations. The purpose is to ensure that service is provided according to the treatment plan, needs of the patients are being met, coordination of care is provided within the agency, with physicians and across the health care continuum, services are provided efficiently and effectively to promote, achieve and maintain the patient’s optimum state of health and function.

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 record review and interview the home health agency failed to send a completed discharge summary to the primary care provider or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency within 5 business days of the patient’s discharge for 3 of 3 sampled discharge patients (#10, #11, and #13). The findings include: A review of sampled patient’s #10 medical record revealed a discharge date of 7/10/2022. The medical record did not reveal a discharge summary. A review of sampled patient’s #11 medical record revealed a discharge date of 1/06/2022. The medical record did not reveal a discharge summary. A review of sampled patient’s #13 medical record revealed a discharge date of 9/02/2022. The medical record did not reveal a discharge summary. An interview with the Director of Nursing (DON) was conducted on 10/26/2022 at approximately 1:55 PM. The DON confirmed there were no discharge summaries for all three sampled discharged patients.