Every finding on record at Bond County Treasurer

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/28/2024. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Recertification survey conducted on 5/29/2024. Standard level deficiencies cited. Recommend recertification based on an acceptable Plan of Correction. Abbreviations: Pt – Patient # - Number SOC – Start of care E- Employee POC – Plan of care SN – Skilled nursing

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 1 of 7 (Pt #6) medical records reviewed, the Agency failed to ensure staff provided care per the physician’s orders. Findings include: 1. Pt #6 SOC (Start of Care): 2/21/2023 Diagnosis: Disruption of external operation-surgical wound. The medical record was reviewed on 5/28/2024 at approximately 2:45 PM. The Plan of Care (POC) dated 4/16/2024, noted Skilled Nursing (SN) to assess patient’s weight log every visit. Six of seventeen Skilled Nurse Visit notes between 4/19/2024 to 5/16/2024, lacked documentation weights were obtained as ordered on the POC. 2. An interview was conducted on 5/29/2024 at approximately 12:30 PM with the Home Health Director (E #2). E #2 reviewed Pt #6’s medical record and verbally agreed Pt #6’s weights were not obtained as ordered on the POC and should have been.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/26/2021. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP), for this survey.

A recertification survey was conducted i conjunction with a Focused Infection Control (FIC) survey on 05/26/2021. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: CHF-congestive heart failure E-employee EP-emergency preparedness HHA-home health agency POC-plan of care Pt - patient #-number

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 document review and staff interview, it was determined for 1 of 6 patients (Pt #3) receiving therapy services, the Agency failed to notify the physician for continuation of therapy services. This has the potential to affect all patient patients receiving therapy services from an Agency with a current census of 44. Findings include: 1. On 05/25/2021 at approximately 1:00 PM, the medical record of Pt #3 was reviewed. Pt #3's start of care was 04/08/2021, with diagnosis of malignant neoplasm of right breast. The plan of care for certification period of 04/08/2021 thru 06/06/2021, indicated the patient received a physical therapy evaluation on 04/29/2021 and it determined the patient needed to receive therapy once a week for three weeks. The last physical therapy visit was conducted on 05/11/2021. There were no physician orders for continuing therapy treatments and no order discharging the patient from physical therapy services. 2. On 05/25/2021 at approximately 11:40 PM, an interview with the Agency Director (E #1) was conducted. E #1 confirmed there were no physician orders for continuing therapy treatments for Pt #1. E #1 stated "There should have been continuation orders or a discharge order."

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, it was determined for 1 of 7 patients (Pt #6), the Agency failed to ensure the Plan of Care (POC) addressed all of the patient's problems. This has the potential to affect all patients receiving care from an Agency with a census of 44. Findings included: 1. On 05/25/2021 at 11:00 AM, the clinical record of Pt #6 was reviewed. Pt #6 was admitted to the Agency on 04/26/2021, with the diagnosis of congestive heart failure (CHF). The degree of symptom control on admission was rated 4- symptoms poorly controlled; history of re-hospitalizations. The plan of care for certification period 4/26/2021 thru 6/24/2021 failed to address interventions appropriate for the diagnosis of CHF, daily weight self monitoring program. Subsequently, on 05/14/2021 the patient was prescribed lasix 80 mg (milligrams) every AM, 40 mg every PM for 2 days then 40 mg daily for CHF. 2. On 05/25/2021 at 2:00 PM, a request was made to the Agency Director (E #1) for an Agency policy related to the content of the plan of care. E #1 was unable to provide a policy. 3. On 05/25/2021 at 2:00 PM, an interview with the Agency Manager (E #1) was conducted. E #1confirmed the plan of care did not address monitoring the patient for CHF symptoms. "The plan of care should have addressed daily weights as an intervention, as well as a daily weight log."

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 document review and staff interview, it was determined for 2 of 7 patients (Pt #2, Pt #6) clinical records reviewed, the Agency failed to ensure all documentation was accurate, complete and in the patient's record. This has the potential to affect all patients receiving care at an Agency with a current census of 44 patients. Findings include: 1. Pt #2 SOC 4/30/2021 Admitting Diagnosis: Cellulitis of groin. The clinical record of Pt #2 was reviewed on 5/24/2021, at approximately 1:00 PM. The record lacked nursing documentation for visit notes on 5/3/2021, 5/5/2021, 5/10/2021,5/12/2021, 5/17/2021 and 5/19/2021. Nursing visits were conducted during these dates. 2. Pt #6 SOC 4/26/2021 Admitting Diagnosis: Congested Heart Failure (CHF). The clinical record of Pt #6 was reviewed on 5/25/2021 at approximately 11:00 AM. The Plan of Care for certification period 4/26/2021 through 6/24/2021 stated Pt #6 was to be resuscitated. Pt #6's "POLST" form dated 4/11/2021 indicated Pt #6 was a Do Not Attempt Resuscitation/DNR. No Resuscitation required during the certification period. 3. During an interview with the Agency Director (E #1) on 5/25/2021 at 2:30 PM, it was confirmed that documentation in the clinical record for Pt #2 and Pt #6 were not accurate and complete, and entered in a timely manner. "I'm currently addressing that issue with that nurse." :