Every finding on record at Aunova Home Care LLC

This was a federal and state complaint survey. Facility ID: 013602 Provider # 157683 Dates of Survey: 03/24/2021 - 03/29/2021 Current Census: 49 Complaint # IN00347950 - Allegations: Resident/Patient/Client Rights, Quality of Care/Treatment, Nursing Services: Substantiated with findings This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure it adhered to patient rights by failing to ensure all agency patients were informed in advance of (but not limited to) any changes in the care such as types, discharges or frequency of visits to be furnished for 1 of 4 discharged records reviewed (#4), and failed to ensure a plan of care was incorporated into the patient's home folder for 1 of 1 home visits observed with record review (#7). The findings include: 1. Review of an agency policy dated 01/2018 titled "Patient's Bill of Rights" stated "Patients Rights ... Participate in, be informed about, and consent to or refuse care in advance and during treatment ... establishing and revising the plan of care ... disciplines that will furnish the care ... any changes in the care ...." Additionally, the agency failed to provide a policy on how to furnish care to patients who were symptomatic for COVID-19. 2. Review of an undated agency policy titled "Code of Ethics" stated "... Patient Rights and Responsibilities ... Patient Rights and Responsibilities shall be respected by all agency personnel and integrated into all agency health care programs...." 3. Review of an agency policy dated 01/2018 titled "Physician Role in Home Care of Patients Plan of Care and Interim Orders" stated "... Each patient has an individualized plan of care. The plan is developed and evaluated in partnership with the patient, representative (if any), and caregiver(s) ... Any revision to the plan of care ... is communicated to: 1. The patient; 2. The representative (if any); 3. The caregiver...." 4. During a home visit with patient #7 on 3/29/2021 at 11:45 AM, the patient's home folder was observed and failed to evidence a current plan of care. PTA [physical therapy assistant] F indicated she did not drop off a copy of the plan of care for the home folder. During an interview on 3/29/2021 at 2:05 PM, when asked if agency staff provided a current/updated copy of the patients' plans of care to all patients' homes to incorporate into the home folders, the administrator stated "No ...." and indicated the agency would begin doing that. 5. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the Musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 12/17/2020-2/14/2021, and signed by the primary care physician on 12/17/2020. This document had a subsection titled "21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)." This subsection stated "... Skilled nursing [evaluation] eval only ...." A record review evidenced an agency document titled "AuNOVA Home Care - Admission Consent," dated 12/17/2020, signed by patient #4 and (Registered Nurse) RN G. This document had a subsection titled "Consent for Treatment." This subsection indicated the agency was to provide (Physical Therapy) PT evaluation and treatments. The document failed to include the RN initial evaluation completed by the agency. During an interview on 3/29/2021 at 3:44 p.m., the administrator indicated she believes nursing only did an initial evaluation because the patient was an ortho (orthopedics) case, which did not require regular visits from the nurse. The admission paperwork should have indicated the skilled nursing (SN) evaluation. 17-12-3(b)(2)(D)(i)(AA) 17-12-3(b)(2)(D)(i)(BB) 17-12-3(b)(2)(D)(ii)(AA) 17-12-3(b)(2)(D)(ii)(BB) 17-12-3(b)(2)(D)(iii)

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received all services outlined in the individualized plans of care for 2 of 7 records reviewed (#1, 7). The findings include: 1. Review of an undated agency policy titled "Admission Policy" stated "... Clients will be accepted for home care with the expectation that the agency can provide the services the client needs ...." 2. Review of an agency policy revised 01/2018 titled "Patient's Bill of Rights" stated "Patients Rights ... Receive all services in the plan of care ...." 3. Review of an agency policy revised 01/2018 titled "Physician Role in Home Care of Patients Plan of Care and Interim Orders" stated "... Each patient has an individualized plan of care. The plan is developed and evaluated in partnership with the patient, representative (if any), and caregiver(s) ... Upon completion of the initial assessment ... complete the development of the plan of care ...." 4. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date (Sunday) 2/7/2021, for certification period 2/7/2021 - 4/7/2021, evidenced a document dated 2/7/2021 titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" which stated "... Interventions planned: ... OT [occupational therapy] referral ... [home health] aide ... patient agrees ... They would like all the services they can get especially at the beginning and decrease them as appropriate...." Review of a document dated 2/7/2021 titled "Home Health Certification and Plan of Care", stated "... home health aide [HHA] orders effective week of 2/7/2021: 1 WK 4 [once weekly for 4 weeks] ...." The document failed to evidence OT was ordered, based on the documented referral for OT on the initial comprehensive assessment and the clinical record failed to evidence the patient or caregiver refused OT. Review of a document dated 2/8/2021, titled "Communication Note" indicated the spouse requested help to shower the patient. Review of a document dated (Thursday) 2/11/2021, titled "Communication Note" indicated the patient's spouse gave the patient a shower and they did not need bathing assistance from the home health aide at that time. During a phone interview on 3/25/2021 at 3:38 PM, the patient indicated she had her surgery (shoulder replacement) and came home on (Friday) 2/5/2021, the agency staff didn't come when they were supposed to, there was a mix up with the nurse, it was just one thing after another, and the first day someone was supposed to come, it was car trouble (and no one came). During a phone interview on 3/26/2021 at 9:43 AM, the patient's spouse indicated the patient got out of the hospital on Friday (2/5/2021), they expected to see a nurse either Friday or Saturday, but the agency said they couldn't get anyone there until Sunday (2/7/2021), and someone came Sunday just to ask questions and sign papers, as of 2/11/2021 no aide had contacted patient to schedule a visit, it was just "too late by then", and he stated "... We never refused OT or aide, but after a while, she was getting better and we just didn't need it. I canceled services (2/17/2021) because the nurses really didn't do anything, and PT (physical therapy) helped a lot, but I didn't need them anymore ...." 5. Record review for patient #7 was completed on 3/29/2021, start of care date 3/16/2021, for certification period 3/16/2021 - 5/14/2021. Record review evidenced a document on letterhead from physician office B dated and signed by physician C on 3/9/2021 which stated "... Review of discharge plans: ... PT/OT to continue to increase strength and endurance ... skilled nursing r/t [related to] medication management; and bath aide ...." Review of a document dated and signed 3/9/2021 by physician C titled "Home Health Order and Documentation of Face-to-Face Encounter" stated "... the following services are medically necessary home health services ... Skilled Nursing ... PT ... OT ... HHA ...." The record failed to evidence OT or HHA was offered to the patient, or the patient declined/refused the services. During a home observation visit on 3/29/2021 at 11:45 AM, family indicated she was not sure if HHA services were offered, and the patient only received PT services. 6. During an interview on 3/24/2021 at 10:42 AM, the administrator indicated the agency had trouble staffing aides. 7. During an interview on 3/29/2021 at 2:05 PM, the administrator indicated referral orders were generic orders, and there was lack of documentation in the medical records that patients were offered and/or declined services ordered..

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all agency patients were advised of the Indiana Department of Health toll free home health telephone hot line, its contact information, or its hours of operation. The findings include: The agency's admission packet/home folder provided to the patient during the admission visit was reviewed on 3/24/2021. The folder included a packet titled "AuNova Home Care Patient Orientation For Home Health Care" which stated "... You may also contact the State's Home Health Hot Line at 1-800-882-6006 (toll free) ...." At 2:20 PM, the surveyor called the number, verified it was the Michigan state hotline number, and the recorded greeting stated "You have reached the state of Michigan complaint hotline ...." The admission packet failed to evidence a home health hotline number for the state of Indiana. During an interview on 3/24/2021 at 3:18 PM, the administrator indicated she would correct the hotline number in all admission packets and ensure all current patients receive the corrected information. 17-12-3(b)(2)(C)

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to arrange a safe and appropriate transfer to other care entities when the needs of the patient exceeded the HHA's capabilities and/or the agency was no longer able to meet the patient's needs, based on the patient's acuity in 2 of 7 clinical records reviewed. (#3, #4) The findings include: 1. Review of the agency policy revised 01/2018 titled "Discharge and Transfer Criteria" stated "... Here are reasons, based on federal requirements, that agencies (AuNOVA Home Care) may transfer or discharge patients: ... The Transfer or Discharge is necessary for the patient's welfare because the organization and the physician who is responsible for the home health plan agree that the agency can no longer meet the patient's needs, based on the patient's acuity...." 2. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the Musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Communication Note," dated 1/13/2021, signed by (Licensed Practical Nurse) LPN I. This document stated "... agency will place patient on hold until negative test or 10-14 days of symptom onset ... No lab draws will be performed during this time ...." A record review evidenced an agency document titled "Communication Note," dated 1/15/2021, signed by person I, former employee. This document stated "... Called patient this morning to follow up on status of covid testing so we could make plans to see patient ... Patient got very irate with me stating wife [patient #3] never had any symptoms, patient was yelling and using foul language with me over the phone ...." A record review evidenced an agency document titled "Communication Note," dated 1/15/2021, signed by person I, former employee. This document indicated the primary care physician was informed that the patient requested a referral to another home care to continue PT and lab draws. A record review evidenced an untitled agency fax document, dated 1/15/1021, and signed by the primary care physician. The document stated " ... Patient discharged from agency due to unsafe environment to continue care ... Discharge from Aunova Homecare ... [primary care physician] to refer to another agency for continuation of care ...." A record review evidenced an agency document titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)," dated 1/17/2021, signed by (Master of Physical Therapy) MSPT H. This document had a subsection titled "Discharge Status." This subsection indicated the patient was discharged to home or self-care (routine discharge). The agency failed to transfer the patient to an appropriate care entity due to being unable to meet the patient's needs as a result of needing a COVID test. The agency failed to provide ordered visits, due to the belief that the patient had COVID symptoms. A record review evidenced an agency document titled "AuNOVA Home Care," dated 1/15/2021, signed by person L, Physician for patient #4. This document stated "... Patient discharged from agency due to unsafe environment to continue care...." During a phone interview on 3/24/2021 at 2:49 PM, patient #4 indicated the person who was supposed to come out on 1/13/21, to do a blood draw never showed up. He indicated they lied about her having the cough/sore throat symptoms, which patient #3 never had. He also indicated they kept cutting him off on the phone and he said to the administrator that she was unprofessional. He indicated that on 1/15/2021 the administrator indicated they would not come out due to COVID and he stated he would not let them come out anymore. 3. Clinical record review on 3/29/21 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (high levels of sugar in the blood), start of care 11/5/2020, evidenced an agency document titled "Patient Assessment: OASIS D1 (Full)," dated 1/17/2021, signed by (registered nurse) RN G. This document had a subsection titled "Discharge Status." This subsection indicated the patient was discharged to home or self-care (routine discharge). The agency failed to transfer the patient to an appropriate care entity due to being unable to meet the patient's needs as a result of needing a COVID test. During a phone interview on 3/24/2021 at 2:40 PM, patient #3 indicated they discharged her because she wouldn't go get a COVID test. During an interview on 3/29/2021 at 3:31 PM, the administrator indicated if the patients have any COVID like symptoms despite a fever, we would wait 10 days or get a COVID test.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document both the existence of a complaint and the resolution of the complaint for 2 of 2 records reviewed with complaint(s) made to the agency. (#3, 4) The findings include: 1. Review of an agency policy dated (revised) 01/2018, titled "Patient Complaints" stated "... A complaint is any expression of dissatisfaction by the client or family ... The organization [agency] investigates complaints made by a patient, the patient's representative ... The organization documents both the existence of the complaint and the resolution of the complaint ... A log is kept of all complaints received ... Source of complaints ... Nature of complaints ... Action taken ... Whether the complaint is resolved ...." 2. Review of the agency's complaint log was completed on 3/24/2021 at 1:22 PM. The log evidenced one complaint in 2017, and evidenced no complaints in 2018, 2019, 2020, or 2021.3. Clinical record review on 3/29/21 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (high levels of sugar in the blood), start of care 11/5/2020, evidenced an unsigned agency document titled "Communication Note" dated 1/15/2021. This document stated "... Based on Patient's spouse's behavior of yelling at [person I, former employee], [Administrator], using foul language and calling Clinicians 'incompetent', 'liar', and accusing staff of 'making stuff up', I asked if given the circumstances patients would like another home care agency to care for them, and spouse agreed...." During a phone interview on 3/24/2021 at 2:32 PM, patient #3 indicated they called the agency when the agency didn't show up a couple days after the last time they came out. She stated they (the agency) took the (Physical Therapist) PT's word about her having a headache and fever and she never had the symptoms the PT claimed she had. She stated her husband eventually told the agency they are not allowed back on 1/15/2021. During a phone interview on 3/24/2021 at 2:35 p.m., patient #3 indicated the PTA [Physical Therapy Assistant] didn't know how to use the thermometer as she did not have it in her ear correctly. She indicated she was laying on a heated blanket on that side prior to having her temperature taken, and that was why the thermometer read high. During a phone interview on 3/24/2021 at 2:40 p.m., patient #3 indicated they discharged her because she wouldn't go get a COVID test. 4. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the Musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Physical Therapy Process," dated 1/12/2021, signed by (Physical Therapy Assistant) PTA E. This document had a subsection titled "Subjective reports:." This subsection stated "... Took [patient #3] patience [sic] temperature with patient's ear thermometer which registered 101.0 degrees Fahrenheit. subsequently took patients temperature with my thermometer which was a temporal thermometer which registered 98.5 degrees...." A record review evidenced an agency document titled "Communication Note," dated 1/13/2021, signed by (Licensed Practical Nurse) LPN I. This document stated "... agency will place patient on hold until negative test or 10-14 days of symptom onset ... No lab draws will be performed during this time ...." A record review evidenced an agency document titled "AuNOVA Home Care," dated 1/15/2021, signed by person L, Physician for patient #4. This document stated "... Patient discharged from agency due to unsafe environment to continue care...." Was this cited under a patient rights discharge tag? It was not. Should I add it to the tag I wrote for G454? I added this to G454 A record review evidenced an agency document titled "Communication Note," dated 1/15/2021, signed by person I, former employee. This document stated "... patient request a referral to another home care to continue (Physical Therapy) PT and labs draws per oncologist...." A record review evidenced an agency document titled "Communication Note," dated 1/15/2021, signed by person I, former employee. This document stated "... Called patient this morning to follow up on status of covid testing so we could make plans to see patient ... Patient got very irate with me stating wife never had any symptoms, patient was yelling and using foul language with me over the phone ...." A record review evidenced an unsigned agency document titled "Communication Note," dated 1/15/2021. This document stated "... [Person I, former employee] was on phone with patient who was using foul language and yelling at clinician for 'lying' about symptoms ... Upon speaking with patient, he informed me that his dr [doctor] called him and told him and his wife that he didn't think they needed to get tested and had no symptoms ... He continued to say PTA was 'lying' and used the patient's thermometer incorrectly which is why she had a reading of 101 and when used her own thermometer the reading was normal in 98 ... He continued to say spouse had no symptoms ... patient was not receptive and started raising his voice ... At this point, I did tell him ... given the circumstances, would you like the referral to be made to another home care agency for both of you'. Patient states 'absolutely, we don't trust you at all'...." Review of the agency's complaint log was completed on 3/24/2021. The log evidenced one complaint in 2017, and evidenced no complaints in 2018, 2019, 2020, or 2021. The agency failed to document both the existence and resolution of the complaint. (new paragraph to indicate the complaint was not documented) During a phone interview on 3/24/2021 at 2:49 PM, patient #4 indicated the person who was supposed to come out on 1/13/21, to do a blood draw never showed up. He indicated they added the cough/sore throat symptoms, which patient #3 never had. He also indicated they kept cutting him off on the phone and he said to the administrator that she was unprofessional. He indicated that on 1/15/2021, the administrator indicated they would not come out due to COVID and he stated he would not let them come out anymore. During an interview on 3/29/2021 at 2:05 PM, the administrator indicated she was the final person who was on the phone with patient #4, he was loud, aggressive, and yelling, he indicated his physician didn't want him to get a COVID-19 test, the therapist was a liar, and he was upset about incompetent staff. 5. During an interview on 3/24/2021 at 10:42 AM, the administrator indicated complaints were documented in the agency complaint log, the agency had no complaints documented, the agency had not had any "official" complaints, the agency had not had any patients that called and complained, and if complaints were made to staff during home visits, the complaint would be identified in the patient's medical record. 17-12-3(c )(2)

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 record review and interview, the agency failed to ensure a registered nurse (RN) conducted the initial assessment visit for 1 of 1 records reviewed for patients who received both nursing and therapy services (#1); failed to ensure the initial assessment visit was made 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 for 2 of 7 records reviewed (#6, 7); and failed to ensure the initial assessment was made based on patient need, not agency convenience or availability for 3 of 7 records reviewed (#1, 6, 7). The findings include: 1. Review of an undated agency policy titled "Admission Policy" stated "... Clients will be accepted for home care with the expectation that the agency can provide the services the client needs and that the client's condition can be managed safely ... Initial Assessment Visit: A home visit is made ... within 48 hours of referral or according to physician's orders and/or patient/family wishes...." 2. Review of an undated agency policy titled "Comprehensive Assessments and OASIS [outcome assessment information data set]" stated "... The SOC [start of care/admission] Assessment is completed in a timely manner (within 48 hours) ... Referral to other disciplines for Evaluation ... will be completed no later than 2-5 days after the start of care ...." 3. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date (Sunday) 2/7/2021, for certification period 2/7/2021 - 4/7/2021. The record failed to evidence the initial assessment was completed by a registered nurse when both nursing and therapy was ordered, and failed to ensure the initial assessment was made based on patient need, not agency convenience or availability. The initial comprehensive assessment was completed, dated 2/7/2021, and signed on 2/11/2021 by PT H. Review of a document dated and signed by physician D on 2/5/2021, titled "AuNova Home Care Provider Referral/Order Form" stated "... Home Health Skilled Services to eval & treat: ... Skilled Nursing ... Physical Therapy [PT] ... Occupational Therapy [OT] ... Home Health Aide [HHA] ...." Review of an unsigned document (unknown author) dated 2/5//2021 at 10:19 AM, titled "Referred for Admission [order]" evidenced physician D was the referring physician, and stated "... Received referral from [hospital E] for SN [skilled nursing] PT OT HHA. Patient will be DC [discharged] to home on 2/5/2021. Dr. [physician F] to follow ...." Review of a document dated and signed by the clinical manager on 2/5/2021 at 3:40 PM, titled "Admission Order" evidenced the ordering physician was physician assistant (PA) G, the patient was discharged to home on 2/5/2021, agency to admit on 2/7/2021 (PT to perform initial assessment), and RN to assess on 2/8/2021 for incision monitoring and constipation education. Review of a document dated and signed by PT H on 2/5/2021, titled "Communication Note" stated "... AuNova Home care received notification from [hospital E] regarding patient fall at home today. This therapist called [physician assistant G] reporting fall and unknown status of patient. He stated patient should call him to report her current status and he will decide what needs to be done. He stated she should go directly to urgent care or ER [emergency room] if any musculoskeletal or neurological injuries noted. This therapist requested clarification on home care orders. PA stated patient should have no shoulder movement for 2 weeks after surgery. Ok for ELBOW PROM [passive range of motion] only during that time. PT to address home accessibility/safety with navigation, ambulation. He stated OT for ADLs [activities of daily living], SN and bath aid all would be appropriate as needed for patient. This therapist spoke with patient's husband ... and provided information from PA including his direct number to call to report physical status since fall. (He stated patient fell in home while walking to bathroom. Is sore but doesn't think she hurt herself/shoulder). He took name and number of PA and stated he would call. Scheduled PT SOC for 2/7/21 at 11:00, with husband ...." Review of the initial assessment document dated 2/7/2021 and signed on 2/11/2021 by PT H, titled "Patient Assessment: OASIS D1 (Full)" stated "... Interventions planned: ... OT [occupational therapy] referral ... [home health] aide ... patient agrees ... They would like all the services they can get especially at the beginning and decrease them as appropriate ...." The document evidenced it was the initial start of care comprehensive assessment, and the visit was not performed by a registered nurse. During a phone interview on 3/25/2021 at 3:38 PM, the patient indicated she had her surgery (shoulder replacement) and came home on (Friday) 2/5/2021, the agency staff didn't come when they were supposed to, there was a mix up with the nurse, it was just one thing after another, and the first day someone was supposed to come, it was car trouble (and no one came). During a phone interview on 3/26/2021 at 9:43 AM, the patient's spouse indicated the patient got out of the hospital on Friday (2/5/2021), they expected to see a nurse either Friday or Saturday, but the agency said they couldn't get anyone there until Sunday (2/7/2021), and someone came Sunday just to ask questions and sign papers, as of 2/11/2021 no aide had contacted patient to schedule a visit, it was just "too late by then", and he stated "... We never refused OT or aide, but after a while, she was getting better and we just didn't need it. I canceled services because the nurses really didn't do anything, and PT (physical therapy) helped a lot, but I didn't need them anymore ...." 4. Record review for patient #6 was completed on 3/26/2021 and again on 3/29/2021, start of care date 3/1/2021, for certification period 3/1/2021 - 4/9/2021, evidenced an undated document titled "Patient Profile" which stated "... Received referral from [hospital A] for SN [skilled nursing] PT OT HHA. Patient will be DC [discharged] to home on 2/24/2021 ...." Review of a document dated and signed by the clinical manager on 2/25/2021, and signed by physician M on 3/10/2021 titled "Admission Order" stated "... Patient discharged [from hospital] to home on 2/25/2021 ... [nurse at physician M's office] verified MD [medical doctor] to follow for home health. Upon calling to schedule start of care patient requested to be seen on 3/01/2021 ...." The document failed to evidence the physician was notified of the change in start of care date during the phone conversation with nurse at physician M's office on 2/25/2021. 5. Record review for patient #7 was completed on 3/29/2021, start of care date 3/16/2021, for certification period 3/16/2021 - 5/14/2021, evidenced a document dated and signed by physician C on 3/9/2021 titled "[physician clinic B letterhead]" stated "... planning to discharge home 3/10 [2021] ... Review of discharge plans: ... PT/OT to continue to increase strength and endurance ... skilled nursing r/t [related to] medication management; and bath aide...." Review of a document dated and signed by RN G on 3/12/2021 at 10:12 AM titled "Admission Order" stated "... discharged to home on 3/10/2021 ... [physician N's office] verified MD will be following for home health. Upon calling to schedule start of care patient requested to be seen on 3/16/2021 ...." The document failed to evidence the physician was notified of the change in start of care date during the phone conversation with physician N's office on 3/12/2021. During a home observation visit on 3/29/2021 at 11:45 AM, family indicated they did not request to delay the start of care for home health services (6 days) when the patient came home from skilled nursing rehab facility H. 6. During an interview on 3/29/2021 at 2:05 PM, the administrator indicated agency scheduling staff called patients to schedule visits based on staff availability, but then documented it was the patients' request, and that she would address the concern. 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the clinician failed to ensure the comprehensive assessment included a complete picture of the patient's current health status for 5 of 7 clinical records reviewed (#1, 2, 3, 4, 5). The findings include: 1. Review of an undated agency policy titled "Admission Policy" stated "... The comprehensive assessment including Outcome and Assessment Information Set (OASIS) ... includes, at a minimum, a thorough evaluation of the client, his functional limitations, needs and desires, the abilities and willingness of any family care givers, and the adequacy of the environment...." 2. Review of a web reference site on 03/25/2021 at http://1797f0cd94.nxcli.net/wp-content/uploads/2019/09/ap_patient-brochure_catheterremoval-mk-00456-rev1_90d.pdf titled "On-Q* Catheter Removal" stated "... The catheter is a small tube near your incision site that is connected to your infusion pump ...." 3. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date 2/7/2021, for certification period 2/7/2021 - 4/7/2021. Clinical record review evidenced a document dated 2/7/2021 titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)". The document failed to evidence PT H assessed the patient's vital signs (blood pressure, heart rate, respirations, and temperature), heart and lung sounds, or the patient's On-Q ball (a non-narcotic pain pump) present on the patient's left upper arm. Review of a document dated 2/4/2021 titled "Discharge Summary Note" (from hospital E) evidenced the patient had a left shoulder replacement, and stated "... Sling in place on LUE [left upper extremity], anesthesiologist and hospitalist in with patient discussing the On-Q ball. Spouse was present ...." During an interview 3/26/2021 at 9:43 AM, the patient's spouse stated "... I had to remove the Q Ball myself, because she said she couldn't do anything with it ... She wasn't a nurse ... I also took off the dressing myself ...." During an interview on 3/29/2021 at 2:05 PM, the clinical manager indicated the patient's husband was uncomfortable with the removal of the Q-ball, and PT H "walked him through it". During this time, the administrator stated "... I'm surprised that [PT H] didn't add that [presence of the Q-ball] to her start of care assessment ...." The clinical manager and administrator agreed the assessment failed to evidence vital signs, heart and lung sounds, or the patient's On-Q ball present on the patient's left upper arm, and the administrator indicated it could put the agency at risk if problems were missed due to not being assessed during the comprehensive assessment. 4. Record review for patient #2 was completed on 3/26/2021 and again on 3/29/2021, start of care date 2/10/2021, for certification period 2/10/2021 - 4/10/2021, evidenced a document dated 2/10/2021 and signed by PT H on 2/14/2021 titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)". The document evidenced the patient was discharged from the hospital on 2/8/2021, and failed to evidence PT H performed a head to toe assessment of the patient's integumentary (skin) system. Review of a document dated and signed by PTA E on 2/15/2021 titled "Physical Therapy Progress" stated "... Communicated with [clinical manager] ... also communicated with initial evaluation [PT H] regarding patients [sic] pressure sore to left heel ...." Review of a document dated and signed 2/15/2021 by PT H titled "Communication Note" stated "... pressure sore on ... L [left] heel that patient states occurred while in hospital ...." Review of a document dated and signed by RN G on 2/18/2021 titled "Skilled Nurse Visit Note" indicated the wound on the patient's left heel was a stage 2 (limited to layers of the skin, not underlying tissues) pressure sore. The document also included a picture, which evidenced presence of eschar/necrotic (dead skin tissue) tissue, which would indicate a more severe wound. During an interview on 3/26/2021 at 3:45 PM, the patient indicated she developed the sore on her left heel while she was in the hospital, and a nurse came out to treat it (at her home). During an interview on 3/29/2021 at 2:05 PM, the patient's record was reviewed with the clinical manager and administrator. During this time, the clinical manager observed a picture of the patient's left heel pressure sore and indicated it looked like it had presence of eschar/necrosis , and it was possibly a stage 3 or 4 wound (full thickness, beyond depth of all skin layers). 5. Record review for patient #5 was completed on 3/29/2021, start of care date 3/12/2021, for certification period 3/12/2021 - 5/10/2021, evidenced a document dated and signed by PT J on 3/12/2021 titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" evidenced the patient was discharged from hospital J on 3/10/2021, the patient had a right hip replacement, and the document failed to evidence the incision was assessed. 6. Clinical record review on 3/29/21 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (high levels of sugar in the blood), start of care 11/5/2020, evidenced an agency document titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)," dated 1/7/2021, signed by RN G. This document had subsections titled "Musculoskeletal, Neurological," "Nutritional Status," and "Equipment and Supplies." The clinician failed to include the patient's musculoskeletal and neurological status; the overweight status of the patient; and include the equipment (wheelchair, walker, transfer chair, grab bars, shower chair, and hospital bed) the patient is using, in the comprehensive assessment. During an interview on 3/29/2021 at 2:59 PM, the Administrator indicated RN G did not check the box for musculoskeletal/neurological status (for patient #3). It did not say whether it was normal or abnormal. During an interview on 3/29/2021 at 3:03 PM the Clinical Manager indicated the patient (patient #3) was considered obese. She indicated that should have been addressed. During an interview on 3/29/2021 at 3:07 PM, the Administrator indicated the durable medical equipment was not addressed here (for patient #3). 7. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Patient Assessment: OASIS D1 (Full)," dated 12/17/2020, signed by RN G. This document had a subsection titled "Neck and Throat." The clinician failed to include the status of the neck and throat in the comprehensive assessment. During an interview on 3/29/2021 at 3:38 PM, the Administrator indicated if the neck and throat status (for patient #4) was blank, then I'm going to say that it was not assessed. 17-14-1(a)(1)(B)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure admitting clinicians completed a medication profile that included drug regimen review as part of the initial comprehensive assessment, and failed to immediately notify the physician to resolve issues identified for 4 of 7 records reviewed (#1, 2, 3, 6). The findings include: 1. Review of an undated agency policy titled "Medication Monitoring/Orders/Teaching/Documentation" stated "... Patients will be monitored for significant side effects, contraindications and response to medications ... Agency will follow appropriate standards of practice and regulations regarding medications ... Medication review will be included in the periodic comprehensive assessment ... staff shall check all medications ... and promptly report to the physician any significant side effects or contraindications ... For patients receiving therapy only, the Therapist will record all the medications the patient is currently taking ... are reviewed by a nurse ... within 10 business days of the Comprehensive Assessment being completed ...." The policy failed to evidence the medication review, drug regimen review, and notification to the physician for potential clinically significant medication issues must be completed as part of the initial comprehensive assessment. 2. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date (Sunday) 2/7/2021, for certification period 2/7/2021 - 4/7/2021. Review of an undated, unsigned document for episode period 2/7/2021 - 4/7/2021, titled "Patient Medication Profile" evidenced the patient's current medications included (but not limited to) norco (hydrocodone, a narcotic pain medication), metoprolol succinate (medication to treat chest pain/angina, heart failure, and high blood pressure), amiloride HCL (medication to treat high blood pressure, heart failure, or extra fluid in the body), and levetiracetam (a medication to treat seizures). Review of an undated, unsigned document for episode period 2/7/2021 - 4/7/2021, titled "Drug Interaction" stated (but not limited to) "... Severity: 4 metoprolol and amiloride ... Possible serious drug/drug interaction ... Severity: 4 ... hydrocodone ... Possible serious drug/drug interaction ... Severity: 4 levetiracetam and hydrocodone ... Probable serious and possibly life threatening drug/drug interaction ...." Clinical record review evidenced a document dated and signed by PT [physical therapist] H on 2/7/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" which stated "... Did a complete drug regimen review identify potential clinically significant medication issues? ... No - No issues found during review ...." The record failed to evidence the drug regimen review included the serious interactions, or notification to the physician for potential clinically significant medication issues was completed and addressed as part of the initial comprehensive assessment. Review of a document dated and signed on 2/15/2021 by LPN (licensed practical nurse) I titled "Communication Note" stated "... Drug interactions phoned in to MD [medical doctor] office. Medication list mailed to patient. Clinician made aware ...." 3. Record review for patient #2 was completed on 3/26/2021 and again on 3/29/2021, start of care date 2/10/2021, for certification period 2/10/2021 - 4/10/2021. Review of an undated, unsigned document for episode period 2/10/2021 - 4/10/2021 titled "Patient Medication Profile" evidenced the patient's current medications included (but not limited to) norco, pregabalin (a medication used to treat epilepsy, nerve pain, fibromyalgia, and generalized anxiety disorder), and carvedilol (a medication used to treat high blood pressure). Review of an undated, unsigned document for episode period 2/10/2021 - 4/10/2021 titled "Drug Interaction" stated (but not limited to) "... Severity: 4 ... hydrocodone ... Possible serious drug/drug interaction ... Severity: 4 hydrocodone and pregabalin ... Probable serious and possibly life threatening drug/drug interaction ... Severity: 4 ... carvedilol ... Possible serious drug/drug interaction ...." Clinical record review evidenced a document dated 2/10/2021, and signed by PT H on 2/14/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" which stated "... Did a complete drug regimen review identify potential clinically significant medication issues? ... No - No issues found during review ...." The record failed to evidence the drug regimen review included the serious interactions, or notification to the physician for potential clinically significant medication issues was completed and addressed as part of the initial comprehensive assessment. Review of a document dated and signed on 2/15/2021, by LPN I titled "Communication Note" stated "... Drug interactions phoned in to MD office. Medication list mailed to patient. Clinician made aware ...." 4. Record review for patient #6 was completed on 3/26/2021 and again on 3/29/2021, start of care date 3/1/2021, for certification period 3/1/2021 - 4/9/2021, evidenced an undated, unsigned document for episode period 3/1/2021 - 4/29/2021, titled "Patient Medication Profile" which evidenced the patient's current medications included (but not limited to) Humalog (a medication for injection to control diabetes) three times daily, along with a sliding scale (additional amount injected based on blood sugar results), but failed to evidence the sliding scale instructions. 5. During an interview on 3/29/2021, the administrator agreed the drug regimen reviews were not completed and addressed timely. 6. Clinical record review on 3/29/2021 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (Disease process where the body is unable to effectively use insulin to bring glucose into the cells), start of care 11/5/2020, evidenced a document titled "Drug Interaction Report." The document indicated using Clonidine and Carvedilol together induces a major interaction. This document stated "... Drug Interaction Classification ... Major ... Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit ...." Review of an undated, unsigned document for episode period 1/5/2021-3/52021 titled "Patient Medication Profile," evidenced the patient's current medications included (but not limited to) Clonidine (medication used to treat high blood pressure) and Carvedilol (medication used to treat heart failure and high blood pressure). A record review on 3/29/21 for patient #3, evidenced an agency document titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)," dated 1/7/2021, signed by (registered nurse) RN G. This document had a subsection titled "Medication Safety Assessment." This subsection stated "... Medications Reviewed for Drug Duplications and Drug/Drug and Food/Drug Interactions: Yes ...." The document failed to evidence the agency notified the physician for potentially clinically significant medication issues that were identified and addressed as part of the comprehensive assessment. 17-14-1(a)(1)(B)

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to incorporate the OASIS (Outcome and Assessment Information Set) data collected at inpatient facility admission or discharge only, and include the sensory and integumentary status in the OASIS data items in 1 of 7 clinical records reviewed. (#4) The findings include: Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the Musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Patient Assessment: OASIS D1 (Full)," dated 1/17/2020, signed by (Master of Physical Therapy) MSPT H. This document had a subsection titled "Overall Status at Discharge." This subsection stated "... Status information taken from most recent PTA [Physical Therapy Assistant] notes and 30-day reassessment ...." This document had a subsection titled "Sensory Status." This subsection failed to include the Musculoskeletal/Neurological status. This document had a subsection titled "Integumentary Status." This subsection failed to indicate the general skin information. The agency failed to use the initial (registered nurse) RN evaluation at admission to incorporate status information into the discharge OASIS and include the sensory and integumentary status as part of the OASIS data items. During an interview on 3/29/2021 at 3:41 PM, the Administrator indicated the MSPT did the discharge OASIS because the PT [Physical Therapist] was the last discipline in. She (the MSPT) gathered the OASIS information from the PTA and previous OASIS, not the comprehensive assessment.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse failed to update / revise the comprehensive assessment for a change in the patient's condition for 1 of 1 records reviewed with a change in the patient's condition. (#2) The findings include: Review of an undated agency policy titled "Admission Policy" stated "... The comprehensive assessment including Outcome and Assessment Information Set (OASIS) ... includes, at a minimum, a thorough evaluation of the client, his functional limitations, needs and desires, the abilities and willingness of any family care givers, and the adequacy of the environment ...." Review of an undated agency policy titled "Comprehensive Assessments and OASIS" stated "... are completed ... when a significant change in client's condition warrants ...." Record review for patient #2 was completed on 3/26/2021 and again on 3/29/2021, start of care date 2/10/2021, for certification period 2/10/2021 - 4/10/2021, evidenced a document dated and signed by PT [physitcal therapist] H on 2/9/2021 titled "Admission Order" which stated "... admit patient on 2/10/2021 with Physical Therapy ...." Review of a document dated and signed by PT H on 2/15/2021 titled "Other Order - Wound care SN [skilled nurse]" stated "... Pressure sore Left heel ... SN eval/treat wound care L [left] heel ...." Review of a document dated and signed 2/18/2021 by RN G titled "Skilled Nurse Visit Note" evidenced a physical assessment was completed, a stage 2 pressure ulcer (wound development due to unrelieved pressure, limited to layers of the skin) was identified on the patient's left heel, and failed to evidence other required components of a comprehensive assessment were completed, such as (but not limited to) OASIS items, medication review and drug regimen review, functional limitations, rehabilitation potential, and new diagnosis related to the stage 2 pressure ulcer. During an interview and record review for this patient on 3/29/2021 at 2:05 PM, the administrator indicated she did not know the evaluation for the patient's new wound should have been a comprehensive re-assessment with OASIS, and the clinical manager indicated (looked at picture of wound in record) the wound had blackened areas, and looked worse than a stage 2 pressure sore. 17-14-1(a)(1)(B)

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 and interview, the agency failed to ensure all patients' plans of care included all required elements for 6 of 7 patient's plans of care reviewed (#1, 2, 3, 4, 5, 6). The findings include: 1. Review of an agency policy, with a revision date of 01/2018, titled "Physician Role in Home Care of Patients Plan of Care and Interim Orders" stated "... The plan of care includes: ... All pertinent diagnosis [sic] ... All patient care orders, including verbal orders ... Client's mental, cognitive, psychosocial status ... types of services, supplies, and equipment required ... Duration and frequency of visits to be made ... Prognosis and Rehabilitation potential ... Functional limitations ... Nutritional requirements ... Activities permitted ... All medications and treatments ... Food or drug allergies ... Safety measures to protect against injury ... Plans for the patient during a natural or man-made disaster ... A description of the patients risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors ... Patient and caregiver education and training to facilitate timely discharge ... Patient-specific interventions and education ... Homebound status ... Measurable outcomes and goals identified by the organization [agency] and the patient ... Information related to any advance directives; and ... Any additional items the organization or physician may choose to include ...." 2. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date 2/7/2021, for certification period 2/7/2021 - 4/7/2021. This clinical record review evidenced a document dated 2/4/2021, titled "Discharge Summary Note" (from hospital E). This document evidenced the patient was hospitalized for a left shoulder replacement, had a history of (but not limited to) breast cancer, high cholesterol, and seizure disorder, and stated "... Sling in place on LUE [left upper extremity], anesthesiologist and hospitalist in with patient discussing the On-Q ball [non-narcotic pan pump with tube inserted near incision]. Spouse was present ...." Review of a document signed by PT [physical therapist] H on 2/7/2021 and physician assistant (PA) G on 3/1/2021, titled "Home Health Certification and Plan of Care" evidenced the patient's medications included (but were not limited to) kadcyla (a chemotherapy medication used to treat cancer), rosuvastatin (a cholesterol medication), and levetiracetam (an anti-seizure medication), the diagnoses list failed to evidence breast cancer, high cholesterol, and seizure disorder, and failed to evidence presence of the Q-ball pain pump and clinician interventions/patient caregiver teaching. 3. Record review for patient #2 was completed on 3/26/2021 and again on 3/29/2021, start of care date 2/10/2021, for certification period 2/10/2021 - 4/10/2021. This clinical record review evidenced a document dated 2/9/2021, from hospital J, titled "Clinical Summary" which evidenced the patient had active diagnoses of (but not limited to) spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine), chronic back pain, coronary artery disease (CAD), arthritis, acid reflux, and hypothyroidism. Review of a hospital J document dated 1/8/2021, titled "History and Physical" stated "... She [patient] has severe osteoporosis [a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D] ...." Review of a document dated 2/10/2021 and signed by PT H on 2/14/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" evidenced (but not limited to) the patient had severe osteoporosis, obesity, and presence of a cardiac pacemaker/defibrillator (a surgically implanted device to help control abnormal heart rhythms). Review of a document signed by PT H on 2/10/2021, evidenced the patient began taking sulfamethoxazole- TMP (an antibiotic medication) on 2/9/2021, for diagnosis of UTI (urinary tract infection). Review of a document signed by PT H on 2/10/2021, and physician F on 2/26/2021, titled "Home Health Certification and Plan of Care" evidenced the patient's medications included (but were not limited to) alendronate (a medication to treat osteoporosis), apixaban (a blood thinner that reduces blood clotting and reduces the risk of stroke in patients with abnormal heart rhythms), levothyroxine (a medication used to treat hypothyroidism), and pantoprazole (a medication used to treat acid reflux). The document failed to evidence the patient's diagnosis of spinal stenosis, chronic back pain, CAD, arthritis, acid reflux, hypothyroidism, obesity, and presence of a cardiac pacemaker/defibrillator, and failed to evidence the patient's antibiotic medication (sulfamethoxazole- TMP). 4. Record review for patient #5 was completed on 3/29/2021, start of care date 3/12/2021, for certification period 3/12/2021 - 5/10/2021, evidenced a document dated and signed by PT J on 3/12/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" which evidenced (but was not limited to) the patient was discharged from hospital J on 3/10/2021, after a right hip replacement, and the patient had diabetes. Review of a document signed by PT J on 3/12/2021, and physician F on 3/24/2021, titled "Home Health Certification and Plan of Care" evidenced the patient's medications included (but were not limited to) metoprolol (a medication used to treat high blood pressure), docusate sodium (a medication for constipation), atorvastatin (a medication used to treat high cholesterol), atropine/CPM/hyoscyamine/PE/PPA/Scopalamine ER (a medication used to treat irritable bowel syndrome or duodenal ulcers), pantoprazole (a medication used to treat GERD), and tamsulosin (a medication used to treat an enlarged prostate). The document failed to evidence the dose of atropine/CPM/hyoscyamine/PE/PPA/Scopalamine ER, and failed to evidence diagnoses of diabetes, or diagnoses related to medications the patient took, such as high blood pressure, constipation, high cholesterol, irritable bowel syndrome or duodenal ulcers, GERD, or enlarged prostate. 5. Record review for patient #6 was completed on 3/26/2021 and again on 3/29/2021, start of care date 3/1/2021, for certification period 3/1/2021 - 4/9/2021, evidenced an undated document titled "Patient Profile" which stated "... Received referral from [hospital A] for SN [skilled nursing] PT OT [occupational therapy] HHA [home health aide]. Patient will be DC [discharged] to home on 2/24/2021 ...." Review of a document signed by RN G on 3/1/2021, and physician M on 3/16/2021, titled "Home Health Certification and Plan of Care" evidenced the patient's medications included (but were not limited to) humalog (an injectable medication used to treat diabetes), plus a sliding scale (additional dose based on blood sugar reading) 3 times daily. The document failed to include the parameters for the administration of the sliding scale insulin. 6. Clinical record review on 3/29/21 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (Disease process where the body is unable to effectively use insulin to bring glucose into the cells), start of care 11/6/2020, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 1/5/2021-3/5/2021, signed by person K, Physician for patient #3, on 1/28/2021. This document had a subsection titled "10. Medications: Dose/Route/Frequency (N)ew (C)hanged." This subsection stated "Mupirocin [antibiotic used to treat skin infections] 2% Topical Ointment (22 gm [grams]) ; apply topically to affected areas three times daily (N) ...." The document failed to include where the affected areas are located to apply the Mupirocin. 7. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the Musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Home Health Certification and Plan of Care," for certification period 12/17/2020-2/14/2021, signed by person L, Physician for patient #4. This document had a subsection titled "Goals/Rehabilitation Potential/Discharge Plans/Referral Plan/Other Notes," which failed to include a goal for pain. During an interview on 3/29/2021 at 3:15 PM, the Administrator indicated that medication [Mupirocin] was discontinued on 1/4/2021. It should have specified the affected area. During an interview on 3/29/2021 at 3:50 PM, the Administrato indicated there was no pain goal. 17-13-1(a)(1)(C ) 17-13-1(a)(1)(D)(ix)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all disciplines assigned to the patients maintained effective interdisciplinary communication to meet the patient's needs and treatment effectiveness for 2 of 7 records reviewed (#1, 4). The findings include: 1. Review of an agency policy dated (revised) 1/2014 titled "Agency Information" stated "... Objectives ... To provide personalized care designed according to the client's needs ...." 2. Review of an undated agency policy titled "Admission Policy" stated "... Clients will be accepted for home care with the expectation that the agency can provide the services the client needs ...." 3. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date (Sunday) 2/7/2021, for certification period 2/7/2021 - 4/7/2021. This clinical record review evidenced a document dated 2/7/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" which stated "... Interventions planned: ... OT [occupational therapy] referral ... [home health] aide ... patient agrees ... They would like all the services they can get especially at the beginning and decrease them as appropriate ...." The clinical record failed to evidence coordination occurred with other disciplines referred to meet the patient's needs for services/treatment. 4. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic (branch of surgery concerned with conditions involving the Musculoskeletal system) aftercare, start of care 12/17/2020, evidenced an agency document titled "Physical Therapy Progress," dated 12/18/2020, signed by (Physical Therapy Assistant) PTA E. This document stated the pain was rated a 6 (on a scale of 0-10 with 0 being no pain and 10 being the most severe pain). The clinician failed to notify the appropriate staff of the pain rating of 6. During an interview on 3/9/2021 at 3:50 PM, Administrator indicated there was no pain goal. She indicated there was no contact with the physical therapist or physician regarding the pain status. During an interview on 3/9/2021 at 3:52 PM, the Clinical Manager indicated the clinicians use common judgement (on whether to notify physical therapist or physician) if there is a change in what they are normally at. 17-12-2(g)

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure it provided patient education and documentation of the patient's response and comprehension of the education for 2 of 7 records reviewed (#1, 2). The findings include: 1. Review on 3/25/2021 of a web reference site http://1797f0cd94.nxcli.net/wp-content/uploads/2019/09/ap_patient-brochure_catheterremoval-mk-00456-rev1_90d.pdf titled "On-Q* Catheter Removal" stated "... The catheter is a small tube near your incision site that is connected to your infusion pump. The color of the catheter may be clear or golden. REMOVAL OF CATHETER ... If your doctor has instructed you to remove the catheter, then follow their instructions keeping in mind these key steps: ... Wash your hands thoroughly with soap and warm water. Dry thoroughly ... Remove the dressing covering the catheter site ... Remove any skin adhesive strips ... Grasp the catheter close to the skin, and gently pull on the catheter. It should be easy to remove and not painful. Do not tug or quickly pull on the catheter during removal. If it becomes hard to remove or stretches, then STOP. Call your doctor. Continued pulling could break the catheter ... Do not cut or pull hard to remove the catheter. WARNING: After you remove the catheter, check the catheter tip for the black marking to ensure the entire catheter was removed. Call your doctor if you don't see the black marking ... Place a dressing over the catheter site as instructed by your doctor ...." 2. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date 2/7/2021, for certification period 2/7/2021 - 4/7/2021. This clinical record review evidenced a document dated 2/4/2021, titled "Discharge Summary Note" (from hospital E). The document indicated the patient had a left shoulder replacement, and stated "... Sling in place on LUE [left upper extremity], anesthesiologist and hospitalist in with patient discussing the On-Q ball [a non-narcotic pain pump]. Spouse was present ...." Review of a document dated 2/7/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" failed to evidence PT [physical therapist] H provided the patient and/or caregiver education related to the patient's On-Q ball, such as (but not limited to) infection control, procedure for removal, inspection of catheter tip, post catheter removal care, or signs and symptoms to report to the physician. During an interview on 3/26/2021 at 9:43 AM, the patient's spouse stated "... I had to remove the Q Ball myself, because she said she couldn't do anything with it ... She wasn't a nurse ... I also took off the dressing myself ...." During an interview on 3/29/2021 at 2:05 PM, the clinical manager indicated the patient's husband was uncomfortable with the removal of the Q-ball, and PT H "walked him through it". During this time, the administrator stated "... I'm surprised that [PT H] didn't add that [presence of the Q-ball] to her start of care assessment ...." The clinical manager and administrator agreed the assessment failed to evidence the patient's On-Q ball present on the patient's left upper arm. 3. Record review for patient #2 was completed on 3/26/2021 and again on 3/29/2021, start of care date 2/10/2021, for certification period 2/10/2021 - 4/10/2021. This clinical record review evidenced a document dated 2/10/2021, and signed 2/14/2021 by PT H titled "Patient Assessment: OASIS D1 (Full)" This document indicated (but was not limited to) the patient had a history of UTIs (urinary tract infections), took preventative antibiotics, and did not know she had a UTI until she was tested in the hospital. The record failed to evidence the patient was educated on signs/symptoms of UTI and when to contact agency and/or physician. 17-14-1(a)(1)(G)

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide all agency patients with a written copy of the plan of care, which included (but was not limited to) all treatments to be provided to the patient by agency personnel for 1 of 1 records reviewed with a home visit (#7). The findings include: 1. During a home visit observation on 3/29/2021 at 11:45 AM, with patient #7, start of care date 3/16/2021, for certification period 3/16/2021 - 5/14/2021, the patient's home folder was reviewed, which failed to evidence a current copy of the patient's plan of care. During this time, PTA [physical therapy assistant] F indicated she did not provide a copy of the plan of care to the patient. 2. During an interview on 3/29/2021 at 2:05 PM, the administrator indicated the agency did not provide a copy of the plans of care to its patients, but was going to begin doing that.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide the patient with the name of the agency's clinical manager for 1 of 1 records reviewed with a home visit (#7). The findings include: 1. During a home visit observation, with patient #7 on 3/29/2021 at 11:45 AM, start of care date 3/16/2021, the surveyor reviewed the patient's home folder. Review of this home folder evidenced a document titled "Your AuNova Home Care Staff". The document indicated (former employee) RN I as the clinical manager, not RN D (the current clinical manager). The patient failed to be provided the information for the current clinical manager. 2. During an interview on 3/29/2021 at 2:05 PM, the administrator indicated RN I worked for the agency from December 2020 through January 2021, was no longer employed with the agency, RN G (admitting clinician) was not paying attention when she completed the admission paperwork with the patient/family, and no other staff noticed the error upon subsequent home visits.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the skilled professionals provided patient and caregiver education in 1 of 7 clinical records reviewed. (#3) The findings include: Review of an undated agency policy titled "Medication Monitoring/Orders/Teaching/Documentation" stated "... The agency will provide the patient and family/caregiver with the information needed to reach and maintain optimum use of medications ... Documentation in the patient record of services provided includes the following: ... Patient/caregiver instruction ... Patient response to teaching...." Clinical record review on 3/29/21 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (Disease process where the body is unable to effectively use insulin to bring glucose into the cells), start of care 11/5/2020, evidenced an agency document titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)," dated 1/7/2021, signed by (registered nurse) RN G. This document had a subsection titled "Sensory Status." This subsection stated "... Partially impaired: cannot see medication labels or newsprint ...." This document indicated under the same subsection that the patient does not use any visual aids. Record review failed to evidence documentation the clinician educated the patient's caregivers on the proper administrations of medications. During an interview on 3/29/21 at 2:55 PM, the Administrator indicated the patient had a son and husband that lived with them. She indicated someone must help her and she has a daughter who is a nurse, but it did not say in the documentation that the family was helping her with her medication.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all clinical document entries were complete, appropriately authenticated, dated, and timed for 6 of 7 records reviewed (#1, 2, 3, 4, 5, 6). The findings include: 1. Record review for patient #1 was completed on 3/25/2021 and again on 3/29/2021, start of care date 2/7/2021, for certification period 2/7/2021 - 4/7/2021. Clinical record review evidenced a document dated 2/5/2021 titled "Communication Note" which evidenced an electronic signature by intake/payroll office person, but failed to evidence a date of the signature; a document dated 2/5/2021, titled "Referred for Admission" failed to evidence any agency staff signature or date of signature; a document titled "Patient Medication Profile" evidenced a section for the signature of an RN (registered nurse) or LPN (licensed practical nurse), but failed to evidence a skilled nurse's signature or date of signature; a document dated 2/20/2021, titled "Patient Assessment: OASIS [Outcome and Assessment Information Set] D1 (Full)" evidenced PT [physical therapist] H electronically signed the document, but failed to evidence a time. 2. Record review for patient #2 was completed on 3/26/2021 and again on 3/29/2021, start of care date 2/10/2021, for certification period 2/10/2021 - 4/10/2021. Clinical record review evidenced a document titled "Patient Medication Profile" This document evidenced a section for the signature of an RN or LPN, but failed to evidence a skilled nurse's signature or date of signature; a document dated and signed by PT H on 2/10/2021, titled "Home Health Certification and Plan of Care", which evidenced additional information was incorporated to the document, effective 2/18/2021, but the document failed to evidence the clinician reviewed and approved the changes; a document dated 1/26/2021,titled "Referred for Admission" failed to evidence any agency staff signature or date of signature; and a document dated 2/8/2021, titled "Communication Note" which failed to evidence a signature or date. 3. Record review for patient #5 was completed on 3/29/2021, start of care date 3/12/2021, for certification period 3/12/2021 - 5/10/2021. This clinical record review evidenced a document titled "Patient Medication Profile" which evidenced a section for the signature of an RN or LPN, but failed to evidence a skilled nurse's signature or date of signature; and a document dated 3/25/2021, titled "Communication Note" which evidenced the administrator's electronic signature, but failed to evidence the date of signature. 4. Record review for patient #6 was completed on 3/26/2021 and again on 3/29/2021, start of care date 3/1/2021, for certification period 3/1/2021 - 4/9/2021. This clinical record review evidenced a document dated and signed 3/1/2021, by RN G titled "Home Health Certification and Plan of Care" which evidenced additional information was incorporated to the document after the RN signed the document, but the document failed to evidence the clinician reviewed and approved the changes. Review of a document dated and signed by PT J on 3/3/2021, titled "Physical Therapy Evaluation/Plan of Treatment" evidenced the evaluation was completed after the RN signed the Plan of Care, and was later incorporated to the document; a document titled "Patient Medication Profile" evidenced a section for the signature of an RN or LPN, but failed to evidence a skilled nurse's signature or date of signature; a document dated 3/1/2021, titled "Communication Note" evidenced the office manager's electronic signature, but failed to evidence the date of signature; and a document dated 3/10/2021, titled "Communication Note" evidenced the administrative assistant's electronic signature, but failed to evidence the date of signature. 5. Clinical record review on 3/29/21 for patient #4, primary diagnosis: Encounter for other orthopedic aftercare, start of care 12/17/2020, evidenced an undated and unsigned document titled "Patient Medication Profile." The agency failed to authenticate the medication profile with a signature, title, and date. A record review evidenced an unsigned agency document titled "Communication Note," dated 1/13/2021. This document indicated the Administrator spoke with the patient. The agency failed to authenticate the communication record with a signature and title. A record review evidenced an unsigned agency document titled "Communication Note," dated 1/12/2021. This document indicated communication was made for possible COVID 19 symptoms. The agency failed to authenticate the communication record with a signature, title, and date of signature. A record review evidenced an unsigned agency document titled "Communication Note," dated 1/15/2021. This document indicated the Administrator communicated with the patient. The agency failed to authenticate the communication record with a signature, title, and date of signature. 6. Clinical record review on 3/29/21 for patient #3, primary diagnosis: Type 2 Diabetes Mellitus (Disease process where the body is unable to effectively use insulin to bring glucose into the cells), start of care 11/5/2020, evidenced an unsigned and undated document titled "Patient Medication Profile." The agency failed to authenticate the medication profile with a signature, title, and date. 7. During an interview on 3/29/21 at 3:55 PM, the Administrator indicated these documents (communication notes) should be signed. She indicated she spoke with the software company about the agency's capabilities to sign these electronic documents, but if they are not a clinician then they cannot sign everything. She indicated clinical people are supposed to sign these documents. 17-15-1(a)(7)