Every finding on record at Caring Community Home Health, Inc

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 6/4/21. Caring Community Home Health, Inc was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: x = times wk = week # = number = greater than SN = Skilled Nurse DOH = Date of hire POC = Plan of care SOC = Start of care BP = blood pressure mmHg = millimeters per mercury RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on the clinical record review, policy review and Staff interview, it was determined that the Agency Staff failed to conform with the Physician orders. This was found in 5 of 7 (Pts.#1, 6, 3, 4 and 7) records reviewed. Findings include: 1. Pt. #1 SOC 02/25/21 Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 06/02/21 at 1:30 PM. The POC dated 04/26/21 required the Physical Therapy services to evaluate and treat. The record lacked documentation regarding a Physical Therapy evaluation, as ordered. 2. Pt. #6 SOC 08/28/20 Diagnoses: Essential (Primary) Hypertension and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 06/03/21 at 9:30 AM. The POC dated 08/28/20 required the SN to perform complete physical assessment each visit and notify the physician of blood sugar, fasting greater than 150 or less than 60. The SN documented "no glucometer" and failed to assess the blood sugar for the entire 9 week certification period, as ordered by the physician. 3. Pt. #3 SOC 04/12/21 Diagnosis: Other Disorder of Right Eye Following Cataract Surgery. The clinical record was reviewed on 6/2/21 at 4:00 PM. The POC for the certification period of 04/12/21 to 06/10/21 with SN frequency "3 wk 1, 2 wk 8". The POC included "orders for Discipline and Treatment: Notify Physician of vital sign parameters out of range: ....Systolic BP: Greater than (>) 160 Less Than () 90 Less than (<) 60 ...." The record contained a Skilled Nursing visit note dated 05/22/21, documented "BP sitting Right: 177/129 mmHg". The record lacked any documentation that physician was notified, as ordered. 4. Pt. #4 SOC 01/21/21 Diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery with Angina Pectoris with Spasm, Type 2 Diabetes. The clinical record was reviewed on 06/03/21 at 9:00 AM. The POC for certification period 01/21/21 to 03/21/21 with SN frequency "2 wk 9" (2 times a week for 9 weeks). The record lacked documentation the SN provided a second visit for weeks 3 to 7. There was no modification in physician orders for change in frequency. The POC required "SN to perform finger stick for blood glucose analysis every visit." The record lacked any documentation of blood glucose for SOC visit on 01/21 and SN visits dated 02/08/21, 02/22/21, 03/01/21 and 03/11/21. The POC also required : "PT frequency: for Evaluation and Treatment." The record lacked any documentation regarding a Physical Therapy evaluation, as ordered. 5. Pt. #7 SOC 01/25/21 Diagnoses: Hypoglycemia, Hypertension, Type 2 Diabetes. The clinical record was reviewed on 06/03/21 at 11:00 AM. The POC for certification period of 01/25/21 to 03/25/21 with SN frequency "2 wk 9" (2 times a week for 9 weeks). The record lacked documentation the SN provided a second visit for weeks 4 to 7, as ordered. 6. On 06/03/21 from 12:00 PM - 1:00 PM, interview was conducted with the Administrator and Director of Nursing. The Administrator and DON confirmed the above findings.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: A. Based on the onsite observations and Staff interview, it was determined that the Agency lacked an available Clinical Manager . This was found on 1 of 4 survey days (June 1, 2021). Findings include: 1. On 06/01/21 between 9:00 AM and 3:30 PM, it was observed that the Agency lacked a Clinical Manager to assist with the Survey process. 2. The above findings were confirmed on 06/01/21 at 12:30 PM with the Visiting Nurse (Employee #1) and at 3:30PM with the Intake Coordinator.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: . A. Based on the onsite observations and Staff interview, it was determined that the Agency lacked qualified individuals to provide updates of the plans of care. This was found on 1 of 4 survey days (June 1 , 2021). Findings include: 1. On 06/01/21 at 9:00 AM, it was observed that the Agency's Clinical Manager was not available to assist with the Survey. It was observed that the Agency's Intake Coordinator (Employee #5) was onsite but did not qualify as a Clinical Manager. Employee #5 did not have any Patient information, updated Plans of Care or schedule information. 2. On 06/01/21 between 9:00 AM and 3:00 PM, it was observed that the Agency lacked a Clinical Manager to assist with the Survey process. At 12:30 PM, the Agency's Licensed Practical Nurse (Employee #1) arrived to assist with the survey. Employee #1 provided Plans of Care that were not updated for the selected home visits. Employee #1 did not meet the qualification of a Clinical Manager. 3. On 6/02/21 at 9:00 AM, interview was conducted with Administrator who confirmed the above findings.