Every finding on record at C.B. Thiel & Associates, Inc

AMENDED 10/29/21 Substantial Allegation Survey Substantial Allegation OH00125108 and 31915 The following deficiencies are based upon substantial allegation OH00125108 and 31915 completed on 09/21/21. Health Care Plus is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to update the comprehensive assessment within the last five days of 60 days certification period. This affected one (Patient #1) of three medical records reviewed. The facility census was 190. Findings include: Review of the medical record for Patient #1 revealed the patient was admitted to the agency on 03/16/21 with the primary diagnosis of dementia. Review of the certification period dated 05/15/21 through 07/13/21 and 07/14/21 through 09/11/21 revealed physician orders for skilled nursing services three times a week for one week, twice a week for one week, three times a week for four weeks, and once a week for a week. Review of Patient #1’s medical record revealed no documented evidence a comprehensive assessment was completed within the last five days of 60 days for the certification period of 07/13/21 through 09/11/21. Interview with Staff B on 09/21/21 at 9:05 AM confirmed there was no comprehensive assessment for the certification period of 07/13/21 through 09/11/21. Review of the policy and procedure titled "Reassessment/Recertification", revised March 2004, revealed the total plan of care must be renewed at least every sixty days or more often as warranted by the condition of the patient/client.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to update the comprehensive assessment at discharge. This affected one (Patient #1) of three medical records reviewed. The facility census was 190. Findings include: Review of the medical record for Patient #1 revealed the patient was admitted to the agency on 03/16/21 with the primary diagnosis of dementia. Review of the certification period dated 05/15/21 through 07/13/21 and 07/14/21 through 09/11/21 revealed physician orders for skilled nursing services three times a week for one week, twice a week for one week, three times a week for four weeks, and once a week for a week. Review of a clinical note dated 07/26/21 revealed the patient’s overall status was poor and the patient was admitted to the hospital. Review of coordination note dated 07/26/21 revealed the patient was admitted to the hospital on 07/26/21 and was admitted directly to hospice upon return to facility. The patient was discharged from the home health agency on 07/26/21. Review of the medical record revealed no documented evidence a discharge assessment was completed for this patient. Interview with Staff B on 09/21/21 at 9:05 AM confirmed the above findings. Review of policy and procedure for Transfer, Referral and Discharge Criteria and Process revised November 2018 revealed when a patient was discharged, transferred, or referred to another organization, relevant information includes at least: reason for transfer or discharge, physical and psychosocial status at the time of transfer or discharge, summary of the care/service provided and progress towards achieving goals, instruction and/or referrals provided to the patient, existence of any advance directives, if applicable, and the date of discharge was the date of the last visit make or date of notification to discharge. The information would be documented on the discharge Oasis or Transfer Oasis.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure treatments were administered only as ordered by a physician or allowed practitioner. This affected (Patient #1) of three medical records reviewed. The facility census was 190. Findings include: Review of the medical record for Patient #1 revealed the patient was admitted to the agency on 03/16/21 with the primary diagnosis of dementia. Review of the certification period dated 05/15/21 through 07/13/21 and 07/14/21 through 09/11/21 revealed physician orders for skilled nursing services three times a week for one week, twice a week for one week, three times a week for four weeks, and once a week for a week. Review of Patient #1’s medical record revealed no documented evidence a comprehensive assessment or plan of care/plan of treatment (485) was developed and signed by the physician for the certification period of 07/14/21 through 09/11/21. Review of the medical record revealed nursing services were provided to the patient on 07/19/21, 07/21/21, 07/24/21, 07/25/21, and 07/26/21 without a signed physician’s order. Interview with Staff B on 09/19/21 at 9:10 AM confirmed he/she provided nursing services to the patient without a signed physician’s order.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review, the agency failed to provide accurate and complete clinical records. This affected three (Patiens #1, #2 and #3) of three medical records reviewed. The facility census was 190. Findings include: 1. Review of the medical record for Patient #1 revealed the patient was admitted to the agency on 03/16/21 with the primary diagnosis of dementia. Review of the certification period dated 05/15/21 through 07/13/21 and 07/14/21 through 09/11/21 revealed physician orders for skilled nursing services three times a week for one week, twice a week for one week, three times a week for four weeks, and once a week for a week. Review of Patient #1’s medical record revealed no documented evidence a comprehensive assessment or plan of care/plan of treatment (485) was developed and signed by the physician for the certification period of 07/14/21 through 09/11/21. Review of patient #1’s clinical notes revealed the nurse documented a written summary of care provided but failed to completed a nursing assessment which included: vital signs, environmental assessment, head/neck assessment, eyes/ears/nose/throat assessment, pain assessment, integumentary (skin) assessment, cardiovascular assessment, respiratory assessment, genitourinary assessment , gastrointestinal assessment , nutritional assessment , cognitive/behavioral assessment, neurological assessment, endocrine/hematopoietic assessment, functional assessment, co-morbidity conditions assessment, changes of service, education, and goals met on 05/19/21, 05/21/21, 05/24/21, 06/03/21, 06/07/21, 06/09/21, 06/22/21, 06/25/21, 06/28/21, 07/4/21, 07/19/21, 07/21/21, 07/24/21, 07/25/21, and 07/26/21. Interview with Staff B on 09/21/21 at 9:20 AM revealed he/she had not completed a visit note report or a complete assessment of the patient on the above dates noted. Staff B also confirmed a comprehensive assessment and a plan of care/plan of treatment (485) was not developed and signed by the physician for the certification period of 07/14/21 through 09/11/21. 2. Review of the medical record for Patient #2 revealed the patient was admitted to the agency on 03/05/21 with the primary diagnosis of open wound left lower leg. Review of the certification period dated 07/03/21 through 08/31/21 revealed physician orders for skilled nursing services three times a week for seven weeks, twice a week for one week, and once a week for one week. Review of patient #2’s clinical notes revealed the nurse documented a written summary of care provided but failed to completed a nursing assessment which included: vital signs, environmental assessment, head/neck assessment, eyes/ears/nose/throat assessment, pain assessment, integumentary (skin) assessment, cardiovascular assessment, respiratory assessment, genitourinary assessment , gastrointestinal assessment , nutritional assessment , cognitive/behavioral assessment, neurological assessment, endocrine/hematopoietic assessment, functional assessment, co-morbidity conditions assessment, changes of service, education, and goals met on 07/08/21, 07/11/21, and 07/19/21. Interview with Staff B on 09/21/21 at 9:25 AM confirmed the above findings. 3. Review of the medical record for Patient #3 revealed the patient was admitted to the agency on 05/07/21 with the primary diagnosis of fistula of stomach and duodenum. Review of the certification period dated 07/06/21 through 09/03/21 revealed physician orders for skilled nursing services twice a week for two weeks and three times a week for seven weeks. Review of patient #3’s clinical notes revealed the nurse documented a written summary of care provided but failed to completed a nursing assessment which included: vital signs, environmental assessment, head/neck assessment, eyes/ears/nose/throat assessment, pain assessment, integumentary (skin) assessment, cardiovascular assessment, respiratory assessment, genitourinary assessment , gastrointestinal assessment , nutritional assessment , cognitive/behavioral assessment, neurological assessment, endocrine/hematopoietic assessment, functional assessment, co-morbidity conditions assessment, changes of service, education, and goals met on 07/02/21, 07/25/21, 07/07/21, 07/09/21, 07/11/21, 07/17/21, 07/19/21, 07/23/21, 07/26/21, and 07/28/21. Interview with Staff B on 09/21/21 at 9:30 AM confirmed the above findings. Review of policy and procedure titled "On-Going Assessments", reviewed 11/13/18, revealed during a home visits the care manager or other discipline re-evaluate the patients/clients according to the problems identified during the initial visit and thereafter. Using the standards of care identified by the agency, the nurse re-assesses each patient/client for: blood pressure, pulse, respirations, temperature, weight (if indicated), breath sounds, skin integrity, bowel sounds; elimination, appetite/diet, metal status, functional status, safety/home environment, patient/client and family/caregiver support, progress towards goals, compliance to treatment medications, patient/client response to care, changes in condition, changes in diagnoses, changes in patient’s/client’s care environment or support systems, and patient satisfaction with care.