Every finding on record at C & Opd, LLC.

Based on the findings of an unannounced, onsite home health agency state re-licensure survey conducted April 13, 2022 through April 15, 2022, C & OPD, was found to be in compliance with the following requirement(s) of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies- Emergency Preparedness.

Based on the findings of an unannounced, onsite home health agency state re-licensure survey conducted April 13, 2022 through April 15, 2022, C & OPD, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 upon review of agency policy, clinical records (CRs) and interview with agency administrator (EMP# 1) and director of nursing (EMP# 2), it was determined the agency failed to ensure duration was included on the plan of care for four (4) of seven (7) CRs reviewed. (CR# 3, CR# 4, CR# 5 and CR# 6) Findings include: Review of policy, '2.8 CARE PLAN' on April 14, 2022 at approximately 12:30 p.m. revealed, "…Steps to be taken in developing the care plan include...1. Collection of baseline dad including all pertinent diagnoses, including mental status, types of services, identification of any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, instructions for timely discharge or referral and any other appropriate items..." Review of CRs conducted on April 14, 2022 between approximately 1:00 p.m. and 3:00 p.m. and on April 15, 2022 between approximately 9:00 a.m. to 2:00 p.m. revealed the following: CR# 3, Start of Care (SOC), 3/18/2022: Certification period reviewed 3/18/2022-5/16/2022. Skilled nursing frequency visit ordered on 3/30/2022 as "3xwk (three times a week) until healed" Frequency order did not include duration of nursing visits. CR# 4, SOC, 11/2/2021: Certification period reviewed 3/2/2022-4/30/2022. Skilled nursing visit ordered on 3/9/2022 as "1wk (one time a week)." Frequency order did not include duration of nursing visits. CR# 5, SOC, 5/11/2021: Certification period reviewed 3/2/2022-4/30/2022. Skilled nursing frequency visit ordered on 3/2/2022 as "3xwk (three times a week) until healed" Physical therapy frequency visit ordered on 3/2/2022 as "1xwk (one time a week) every other week" Respiratory Certified Practitioner frequency visit ordered on 3/9/2022 as "1 month" Frequency orders did not include duration of nursing, physical therapy and respiratory certified practitioner visits. CR# 6, SOC, 9/7/2021: Certification period reviewed 9/7/2021-11/5/2021. Skilled nursing visit ordered on 9/7/2021 as "2xwk x2 wks, (two times a week for 2 weeks) then once weekly." Frequency order did not include duration of nursing visits. Interview with EMP# 1 and EMP# 2 conducted on April 15, 2022 at approximately 3:00 p.m. confirmed the above findings.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based upon review of agency policy, clinical records (CRs) and interview with agency administrator (EMP# 1) and director of nursing (EMP# 2), it was determined the agency failed to ensure skilled nurses notified physician of patient's condition change for one (1) of seven (7) CRs reviewed. (CR# 5) Findings include: Review of policy, '2.8 CARE PLAN' on April 14, 2022, at approximately 12:30 p.m. revealed, "…Home health services from members of the Agency staff, as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan..." Review of CRs conducted on April 14, 2022, between approximately 1:00 p.m. and 3:00 p.m. and on April 15, 2022 between approximately 9:00 a.m. to 2:00 p.m. revealed the following: CR# 5, SOC, 5/11/2021: Certification period reviewed 3/2/2022-4/30/2022. “Orders for Discipline and Treatments… Notify physician of:…Random blood sugar greater than (>) 60 or less than ( Review of Skilled Nursing Visit assessments revealed: - On 3/9/2022, non-fasting blood sugar recorded as ‘269’ - On 3/16/2022, non-fasting blood sugar recorded as ‘189’ - On 3/23/2022, non-fasting blood sugar recorded as ‘145’ - On 3/30/2022, non-fasting blood sugar recorded as ‘132’ - On 4/6/2022, non-fasting blood sugar recorded as ‘144’ No documentation of skilled nurse informing the physician of non-fasting blood sugar value being out of range per the plan of care. Interview with EMP# 1 and EMP# 2 conducted on April 15, 2022, at approximately 3:00 p.m. confirmed the above findings.

Outpatient therapy services CFR(s): 484.105(g) Standard: Outpatient physical therapy or speech-language pathology services. An HHA that furnishes outpatient physical therapy or speech-language pathology services must meet all of the applicable conditions of this part and the additional health and safety requirements set forth in §485.711, §485.713, §485.715, §485.719, §485.723, and §485.727 of this chapter to implement section 1861(p) of the Act. This STANDARD is not met as evidenced by: Based upon review of agency policy, clinical records (CRs) and interview with agency administrator (EMP# 1) and director of nursing (EMP# 2), it was determined the agency failed to ensure for each patient in need of outpatient physical therapy, there is a written plan of care established for one (1) of seven (7) CRs reviewed. (CR# 5). Findings include: Review of policy, '2.9 SERVICE POLICIES-OTHER HEALTH CARE PROFESSIONAL SERVICES' on April 14, 2022, at approximately 11:30 a.m. revealed, "…5. During the initial assessment visit, the qualified therapist (not assistant) must assess the patient’s function, as appropriate, using a method which objectively measure activities of daily living…The measurement results must be documented in the clinical record. The Therapy Evaluation is sent to the physician for signature and is then considered the therapy plan of care." Review of CRs conducted on April 14, 2022, between approximately 1:00 p.m. and 3:00 p.m. and on April 15, 2022, between approximately 9:00 a.m. to 2:00 p.m. revealed the following: CR# 5, Start of Care (SOC), 5/11/2021: Certification period reviewed 3/2/2022-4/30/2022. Outpatient physical therapy frequency ordered: “1xwk every other week (once a week every other week)” No documentation provided of therapy evaluation and therapy plan of care established and set to physician for signature. Interview with EMP# 1 and EMP# 2 conducted on April 15, 2022, at approximately 3:00 p.m. confirmed the above findings.