Every finding on record at Century Homecare LLC

ACTS Reference # MA00034263 A CMS Authorized Complaint Survey was conducted at CENTURY HOMECARE LLC 65 WATER STREET, UNIT 2 WORCESTER, MA 01604 on 10/27/21, 10/28/21, and 10/29/21 to determine compliance with the following Federal Conditions of Participation related to Home Care: -42 CFR 484.50, Patient Rights -42 CFR 484.60, Care Planning, Coordination, Quality of Care -42 CFR 484.75, Skilled Professional Services -42 CFR 484.110, Clinical Records As a result of this complaint survey, the Agency was found to be at standard level noncompliance. A statement of deficiencies was generated as a result of this complaint investigation.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on records reviewed and interviews, for two of three sampled Clients (Client #1 and Client #2), the Agency failed to conduct and document complete investigations regarding allegations of client neglect. Client #1, it was alleged that Nurse #1 did not conduct skilled nursing visits for medication management and assessment, the Agency was unable to provide proof of skilled nursing visits for the period in question, and was unable to provide documentation to support that they conducted a thorough investigation into the complaint allegation. Client #2, it was alleged that there were times when his/her scheduled skilled nursing visits were conducted by a person unknown to and not employed by the Agency, and Nurse #1 confirmed that on at least one occasion, he directed an acquaintance to visit Client #2 to administer medication. Findings include: The Agency’s Policy, titled Patient Complaint Process, undated, indicated the Agency would make all reasonable efforts to ensure that a complaint was resolved as quickly as possible, if the complaint was of significant nature or had legal implications, the matter would be handled by the Assistant Administrator and Administrator who would involve all pertinent departments of the Agency to resolve the matter and keep proper records of the investigation. All complaints would be investigated requiring detailed information from both the complainant and the employee involved. When a complaint issue requires a mandatory report to the Commonwealth, the Assistant Administrator would be responsible for ensuring that the matter was reported within the required time frame. Client #1 was admitted to the Agency in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of the Agency’s Elder Abuse Mandated Reporter Form, signed by the Administrator and dated 8/26/21, indicated the Agency was notified on 8/04/21 of a complaint that Nurse #1 had not performed skilled nursing services to Client #1 as ordered. The Form also indicated it was alleged by Client #2 (and confirmed during interview with Nurse #1) that a person unknown to and not employed by the Agency had visited Client #2 on at least one occasion to provide services required by a skilled nurse. Further review of the Form indicated there was a section of the form that instructed the Agency to return the form to a designated protective service agency, and that section was left blank. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. There was no documentation to support that Client #1 received any nursing visits on 7/10/21, and no documentation to support that Nurse #1 completed an assessment of a change in condition, or notification of a change in condition to Client #1’s physician. Review of Client #1’s medical record indicated there was a Physician’s Order, dated 7/07/21, that indicated he/she was transferred to the Hospital for evaluation on 7/07/21, and home visits were on hold. However, review of The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized on 7/07/21 through 7/09/21. During an interview on 10/27/21 at 1:20 P.M., Clinical Manager #1 said she was notified by Nurse #1 on 7/11/21 of Client #1’s transfer to the Hospital, and said when she wrote the Physician’s Order, dated 7/07/21, she wrote it as a late entry based on the Nurse Progress Notes documented by Nurse #1. Clinical Manager #1 said that up until 7/11/21, she thought Nurse #1 was providing skilled nursing visits twice daily to Client #1. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and said he could not explain why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. Nurse #1 said that on 7/11/21, Client #1 was sent to the Hospital Emergency Department. Review of Nurse #1’s emailed statement to the Agency, dated 9/08/21, indicated Client #1 presented as confused, gait unsteady, and there was foul smelling, loose fecal matter noted smeared on the refrigerator door and bathroom door. The Statement indicated Client #1 initially declined transfer to the Hospital, and indicated Nurse #1 notified Client #1’s family, physician, and Clinical Supervisor #1. The Statement indicated that Client #1 was later transferred to the Hospital. Further review of the Statement indicated there was no reference to the date of the assessment and transfer. During an interview on 10/27/21, at 9:30 A.M., and throughout the survey, the Administrator said she had questioned Nurse #1 regarding what date Client #1 had been transferred to the Hospital, however she had not received a response. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said Nurse #1 admitted that he had a person unknown to and not employed by the Agency conduct at least one Client visit to Client #2. The Administrator said she did not report these findings to the Department of Public Health as Nurse #1 was no longer employed by the Agency at the time of the findings.

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interviews and records reviewed, for two of three sampled Clients, (Client #1 and Client #2), the Agency failed to ensure clients were free from neglect. For Client #1, Nurse #1 failed to provide skilled nursing visits for a period of four days, Client #1 was transferred to the Hospital Emergency Department on 7/11/21, due to significant change, with a decline in condition. For Client #2, Nurse #1 neglected to provide a skilled nursing visit on 6/13/21, and instead had a person unknown to and not employed by the Agency conduct a visit to his/her home to administer medication. Findings include: The Agency’s Policy, titled, Elder Abuse and Neglect in the Home Setting, dated 2013, indicated: -Elder abuse was defined as any intended, knowing, or careless act that caused potential or actual harm to an older person. The harm could be physical, mental, emotional, or financial, and could include neglect. -Neglect was defined as the refusal or failure to provide necessary care, obligations, or duties to a client and could include withholding ordered treatments, and deliberate incorrect documentation of care rendered. The Agency’s Policy, titled, Effective Care Coordination: Communication and Coordination of Care with Physicians and Other Clinicians, Missed Visit Procedure, dated 12/2018, indicated: -Missed visits resulted in a change to the plan of care because care was not provided as ordered by the physician. -Staff would make all efforts to minimize missed visits so patients could receive the care they needed. -If staff missed any visits, they would contact the patient’s emergency contact, and contact the clinical manager or clinical manager on call to report the missed visit. Client #1 was admitted to the Agency in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. Review of Client #1’s medical record indicated there was a Physician’s Order, dated 7/07/21, that indicated he/she was transferred to the Hospital for evaluation on 7/07/21, and home visits were on hold. However review of The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized beginning on 7/07/21, and skilled nursing visits were not conducted. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and Nurse #1 offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21. During an interview on 10/27/21 at 1:20 P.M., Clinical Manager #1 said she was notified by Nurse #1 on 7/11/21 of Client #1’s transfer to the Hospital, and said when she wrote the Physician’s Order, dated 7/07/21, she wrote it as a late entry based on the Nurse Progress Notes documented by Nurse #1. Clinical Manager #1 said that up until 7/11/21, she thought Nurse #1 was providing skilled nursing visits twice daily to Client #1. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said Nurse #1 had completed his documentation for the dates of 7/07/21 through 7/09/21 as back dated entries (on 7/19/21) after Client #1 was hospitalized, and said the Agency was unaware of Client #1’s hospitalization until 7/11/21. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of the Agency’s Elder Abuse Mandated Reporter Form, dated 8/12/21, indicated Client #2 said he/she was not always provided skilled nursing visits twice a day, and indicated Client #2 said there were times when a person unknown to him/her and who was not identified as an Agency employee conducted visits. Further review of the Form indicated that Nurse #1 said that on 6/13/21 for the A.M., visit to Client #2’s home, he instructed a person unknown to and not employed by the Agency to see Client #2 and administer medication. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said Nurse #1 admitted that he had a person unknown to and not employed by the Agency conduct at least one Client visit to Client #2, and said she did not report the allegation or findings regarding a person unknown to the Agency performing client visits.

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 records reviewed and interviews, for two of three sampled clients (Client #1 and Client #2), the Agency failed to ensure complete investigations regarding client complaints were conducted and documented, when it was alleged that Nurse #1 did not perform skilled nursing visits as ordered by the Physician, and the Agency found that there was validity to these allegations. The Agency was unable to provide supporting documentation of complaint investigation findings or resolution to the clients’ families, physicians, or designated protective service agencies and Department of Public Health. Findings include: The Agency’s Policy, titled, Patient Complaint Process, undated, indicated: -All complaints would be investigated by requiring detailed information from both the complaining client/caregiver/representative or family member and the Agency’s employees involved. -The Agency would keep a record of the complaint, the results of the investigation, and the final resolution of the complaint -When a patient complaint issue required a mandatory report to the Commonwealth, the Agency would ensure that the matter was reported within the required time. The Agency’s Policy, titled Mandatory Abuse Reporting Policy, undated, indicated: -It was the primary responsibility of all employees to immediately file a verbal report for any instance of suspected abuse, neglect, mistreatment, or financial exploitation. -The Agency was responsible for investigating any allegations reported -The Agency would provide a written report to the appropriate state department within 48 hours of filing a verbal report -When a complaint issue requires a mandatory report to the Commonwealth, the Assistant Administrator would be responsible for ensuring that the matter was reported within the required time frame. Client #1 was admitted to the Agency in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of the Elder Abuse Mandated Reporter Form, signed by the Administrator and dated 8/26/21, indicated the Agency was notified on 8/04/21 of a complaint that Nurse #1 had not performed skilled nursing services to Client #1 as ordered. The Form also indicated it was alleged by Client #2 (and confirmed during interview with Nurse #1) that an individual not employed by or known by the Agency had visited Client #2 on at least one occasion to provide services required by a skilled nurse. Further review of the Form indicated a section of the form that instructed the Agency to return the form to a designated protective service agency, and the section was left blank. Review of Nurse #1’s emailed statement to the Agency, dated 9/08/21, indicated Client #1 presented as confused, gait unsteady, and there was foul smelling, loose fecal matter noted smeared on the refrigerator door and bathroom door. The Statement indicated Client #1 initially declined transfer to the Hospital, and indicated Nurse #1 notified Client #1’s family, physician, and Clinical Supervisor #1. The Statement indicated that Client #1 was later transferred to the Hospital. Further review of the Statement indicated there was no reference of the date of the assessment or transfer. Review of the Agency’s report filed in the Health Care Facility Reporting System (HCFRS), dated 8/26/21, indicated Nurse #1 said he had provided skilled nursing visits to Client #1 as ordered. The Agency’s report did not indicate that Nurse #1 had erroneously documented that Client #1 was hospitalized from 7/07/21 through 7/09/21, or that there was no documentation to support that skilled nursing visits were conducted on 7/10/21, despite the fact that Client #1 was not hospitalized until 7/11/21. During an interview on 10/27/21, at 9:30 A.M., and throughout the survey, the Administrator said she had questioned Nurse #1 regarding what date Client #1 had been transferred to the Hospital, but said she had not received a response. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said Nurse #1 admitted that he had a person unknown to and not employed by the Agency conduct at least one Client visit to Client #2, and said she did not report the allegation or findings. The Administrator said she did not report these findings to the Department of Public Health as Nurse #1 was no longer employed by the Agency at the time of the findings.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on records reviewed and interviews, for two of three sampled Clients (Client #1 and Client #2), the Agency failed to report allegations and findings of neglect by an employee. Client #1 was not provided skilled nursing services as ordered for a period of four days (7/07/21 through 7/10/21), was transferred to the Hospital Emergency Department on 7/11/21, due to a significant change and decline in condition. Client #2 was not provided skilled nursing services on at least one occasion, when Nurse #1 had a person unknown to and not employed by the Agency go to Client #2’s home to administer medication and conduct a nursing assessment. The Agency did not report the allegations of neglect to the Department of Public Health. Findings include: The Agency’s Policy, titled, Mandatory Abuse Reporting Policy, undated, indicated: Abuse was defined as any intended, knowing, or careless act that caused potential or actual harm to an older person. Abuse could include neglect or mistreatment. Neglect was defined as the refusal or failure to provide necessary care, obligations, or duties to the client, and could include withholding ordered treatments and deliberate incorrect documentation of care rendered. The Agency’s Policy, titled, Patient Complaint Process, undated, indicated that when a patient complaint issue required a mandatory report to the Commonwealth, the Agency would ensure that the matter was reported within the required time frame. The Agency’s Policy, titled Mandatory Abuse Reporting Policy, undated, indicated: -It was the primary responsibility of all employees to immediately file a verbal report for any instance of suspected abuse, neglect, mistreatment, or financial exploitation. -The Agency was responsible for investigating any allegations reported -The Agency would provide a written report to the appropriate state department within 48 hours of filing a verbal report Client #1 was admitted to the Agency in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated it contained nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, with two progress notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. The Agency's Internal Investigation determined that Client #1 was not hospitalized on these days, that the skilled visits should have been conducted and were not, and Nurse #1 backdated and wrote progress notes on 7/19/21 for these visits. Review of Client #1’s medical record indicated there was a Physician’s Order, dated 7/07/21, that indicated he/she was transferred to the Hospital for evaluation on 7/07/21, and home visits were on hold. The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized on 7/07/21 through 7/09/21. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said she had questioned Nurse #1 as to what day Client #1 had been admitted to the Hospital, and said Nurse #1 did not notify Nurse Manager #1 about the transfer until 7/11/21. The Administrator said after the Agency determined that Client #1 was not admitted to the Hospital until 7/11/21 and that Nurse #1 did not conduct visits twice daily as scheduled from 7/07/21 to 7/10/21 they did not report this to the Department of Public Health as required. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of The Agency’s Elder Abuse Mandated Reporter Form, dated 8/12/21, indicated Client #2 said he/she was not always provided skilled nursing visits twice a day, and indicated that Client #2 said there were times when a person unknown to him/her and not employed by the Agency would conduct visits. The Form indicated that Nurse #1 said that on 6/13/21 for the A.M., visit to Client #2’s home, he instructed a person unknown to and not employed by the Agency to see Client #2 and administer medication. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said she did not know who Nurse #1 sent to Client #2's home to conduct that home visit. The Administrator said Nurse #1 did give them a name but said that person was not employed by the agency. The Administrator said she did not report the allegation or findings regarding a person unknown to and not employed by the Agency performing client visits to the Department of Public Health.

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 interviews and records reviewed, for two of three sampled Clients, (Client #1 and Client #2), the Agency failed to ensure staff provided care and services as outlined in the comprehensive plan of care, specifically related to skilled nursing visits, when Nurse #1 did not visit the Clients as ordered. Findings include: The Agency Policy, titled, Planning and Coordination of Patient Care, undated, indicated the Agency would ensure that all patient care was coordinated using an interdisciplinary team approach which supported the implementation of the individualized plan of care for each patient. The Agency’s Policy, titled, Effective Care Coordination: Communication and Coordination of Care with Physicians and Other Clinicians, Missed Visit Procedure, dated 12/2018, indicated: -Missed visits resulted in a change to the plan of care because care was not provided as ordered by the physician. -Staff would make all efforts to minimize missed visits so patients could receive the care they needed. -If staff missed any visits, they would contact the patient’s emergency contact, and contact the clinical manager or clinical manager on call to report the missed visit. Client #1 was admitted to the Agency’s service in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated it included nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not conducted. There was no documentation that Client #1 received any nursing visits on 7/10/21. Per the Agency's Internal Investigation, Nurse #1 wrote the progress notes on 7/19/21, and back dated them. Client #1 did not have home visits on these dates from anyone at the Agency. The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized beginning on 7/07/21. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21. Nurse #1 offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said Nurse #1 had completed his documentation for the dates of 7/07/21 through 7/09/21 on 7/19/21, after Client #1 was hospitalized, and said the Agency was unaware of Client #1’s hospitalization until 7/11/21. The Administrator said there was no documentation to support that Client #1 was hospitalized at all between 7/07/21 through 7/10/21, and said Nurse #1 should have conducted skilled nursing visits as ordered on those dates. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of The Agency’s Elder Abuse Mandated Reporter Form, dated 8/12/21, indicated that Client #2 said he/she was not always provided skilled nursing visits twice a day, and indicated Client #2 said there were times when a person unknown to him/her and not employed by the Agency would conduct visits. The Form indicated that Nurse #1 said that on 6/13/21 for the A.M., visit to Client #2’s home, he instructed a person unknown to and not employed by the Agency to see Client #2 and administer medication. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said she did not know who Nurse #1 sent to Client #2's home to conduct that home visit. The Administrator said Nurse #1 did give them a name but said that person was not employed by the agency. The Administrator said she did not report the allegation or findings regarding a person unknown to and not employed by the Agency performing client visits to the Department of Public Health.

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: Based on interviews and records reviewed, for two of three sampled Clients (Client #1 and Client #2), the Agency failed to ensure care and services were provided as ordered by the Physician, specifically skilled nursing visits, when Nurse #1 did not provide skilled nursing visits to Client #1 on four consecutive days. For Client #2, it was documented that Nurse #1 failed to provide at least one skilled nursing visit, and instead sent a person unknown to and not employed by the Agency to Client #2’s home. Findings include: The Agency’s Policy, titled, Medication Administration and Management, dated 3/2018, indicated nursing staff would administer and document medications as prescribed by the physician. The Agency’s Policy, titled, Planning and Coordination of Patient Care, undated, indicated the Agency would ensure that all patient care was coordinated using an interdisciplinary team approach which supported the implementation of the individualized plan of care for each patient. The Agency’s Policy, titled, Effective Care Coordination: Communication and Coordination of Care with Physicians and Other Clinicians, Missed Visit Procedure, dated 12/2018, indicated: -Missed visits resulted in a change to the plan of care because care was not provided as ordered by the physician. -Staff would make all efforts to minimize missed visits so patients could receive the care they needed. -If staff missed any visits, they would contact the patient’s emergency contact, and contact the clinical manager or clinical manager on call to report the missed visit. Client #1 was admitted to the Agency’s services in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not conducted. Review of the Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. However per the Agency's internal investigation, Nurse #1 wrote the progress notes on 7/19/21 and back dated them for 7/07/21, 7/08/21, 7/09/21, and therefore there were no skilled nursing visits for Client #1 from anyone at the Agency for those dates. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said Nurse #1 had completed his documentation for the dates of 7/07/21 through 7/09/21 on 7/19/21 after Client #1 was hospitalized, and said the Agency was unaware of Client #1’s hospitalization until 7/11/21. The Administrator said there was no documentation to support that Client #1 was hospitalized at all between 7/07/21 through 7/10/21, and said Nurse #1 should have conducted skilled nursing visits as ordered on those dates. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of The Agency’s Elder Abuse Mandated Reporter Form, dated 8/12/21, indicated Client #2 said he/she was not always provided skilled nursing visits twice a day, and indicated Client #2 said there were times when a person unknown to him/her and not employed by the Agency would conduct visits. The Form indicated that Nurse #1 said that on 6/13/21 for the A.M., visit to Client #2’s home, he instructed a person unknown to and not employed by the Agency to see Client #2 and administer medication. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said she did not know who Nurse #1 sent to Client #2's home to conduct that home visit. The Administrator said Nurse #1 did give them a name but said that person was not employed by the agency. The Administrator said she did not report the allegation or findings regarding a person unknown to and not employed by the Agency performing client visits to the Department of Public Health, and said this went against standards of practice.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on records reviewed and interviews, for two of three sampled Clients (Client #1 and Client #2), the Agency failed to ensure staff conducted skilled nursing visits as scheduled. Nurse #1 documented that Client #1 was hospitalized and unavailable for visits on 7/07/21, 7/08/21, and 7/09/21, and there was no documentation related to the 7/10/21 home visit. However Client #1 was not transferred and admitted to the Hospital until 7/11/21, and therefore was not seen by nursing during that period as ordered by the Physician. Client #2 alleged and the Agency’s investigation indicated that on at least on occasion, Nurse #1 sent a person unknown to and not employed by the Agency to conduct assessment and medication administration to Client #2’s home. Findings include: The Agency’s Policy, titled, Planning and Coordination of Patient Care, undated, indicated the Agency would ensure that all patient care was coordinated using an interdisciplinary team approach which supported the implementation of the individualized plan of care for each patient. The Agency’s Policy, titled, Effective Care Coordination: Communication and Coordination of Care with Physicians and Other Clinicians, Missed Visit Procedure, dated 12/2018, indicated: -Missed visits resulted in a change to the plan of care because care was not provided as ordered by the physician. -Staff would make all efforts to minimize missed visits so patients could receive the care they needed. -If staff missed any visits, they would contact the patient’s emergency contact, and contact the clinical manager or clinical manager on call to report the missed visit. Client #1 was admitted to the Agency’s services in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. There was no documentation that Client #1 received any nursing visits on 7/10/21. The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized beginning on 7/07/21. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said Nurse #1 had completed his documentation for the dates of 7/07/21 through 7/09/21 on 7/19/21, after Client #1 was hospitalized, and said the Agency was unaware of Client #1’s hospitalization until 7/11/21. The Administrator said Nurse #1 should have conducted skilled nursing visits as ordered on those dates. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of The Agency’s Elder Abuse Mandated Reporter Form, dated 8/12/21, indicated Client #2 said he/she was not always provided skilled nursing visits twice a day, and indicated Client #2 said there were times when a person unknown to him/her and not employed by the Agency would conduct visits. The Form indicated that Nurse #1 said that on 6/13/21 for the A.M., visit to Client #2’s home, he instructed a person unknown to and not employed by the Agency to see Client #2 and administer medication. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said she did not know who Nurse #1 sent to Client #2's home to conduct that home visit. The Administrator said Nurse #1 did give them a name but said that person was not employed by the agency. The Administrator said she did not report the allegation or findings regarding a person unknown to and not employed by the Agency performing client visits to the Department of Public Health.

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 interviews and records reviewed, for two of three sampled Clients (Client #1 and Client #2), the Agency failed to ensure staff provided care and services, specifically skilled nursing visits, as indicated in the Clients’ plan of care. Client #1 did not receive skilled nursing visits twice daily as ordered from 7/07/21 through 7/10/21, was admitted to the Hospital on 7/11/21 with diagnoses of colitis, diarrhea, and low potassium and magnesium levels. Client #2 did not receive skilled nursing visits as ordered on at least one occasion, when Nurse #1 instructed a person not known or employed by the Agency to visit Client #2 to administer medications and conduct a nursing assessment. Findings include: The Agency’s Policy, titled, Planning and Coordination of Patient Care, undated, indicated client care would be coordinated using an interdisciplinary team approach and agency personnel would coordinate care with the client’s physician. The Agency’s Policy, titled, Effective Care Coordination: Communication and Coordination of Care with Physicians and Other Clinicians, Missed Visit Procedure, dated 12/2018, indicated: -Missed visits resulted in a change to the plan of care because care was not provided as ordered by the physician. -Staff would make all efforts to minimize missed visits so patients could receive the care they needed. -If staff missed any visits, they would contact the patient’s emergency contact, and contact the clinical manager or clinical manager on call to report the missed visit. Client #1 was admitted to the Agency’s service in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. There was no documentation that Client #1 received any nursing visits on 7/10/21. The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized beginning on 7/07/21. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said Nurse #1 had completed his documentation for the dates of 7/07/21 through 7/09/21 on 7/19/21, after Client #1 was hospitalized, and said the Agency was unaware of Client #1’s hospitalization until 7/11/21. The Administrator said there was no documentation to support that Client #1 was hospitalized at all between 7/07/21 through 7/10/21, and said Nurse #1 should have conducted skilled nursing visits as ordered on those dates. Client #2 was admitted to the Agency in March of 2009, diagnoses included falls and diabetes. The Home Health Certification and Plan of Care, dated 5/08/21 through 7/06/21, indicated Client #2 required skilled nursing visits twice daily for physical and mental assessment, medication management, and teaching on disease process. Review of The Agency’s Elder Abuse Mandated Reporter Form, dated 8/12/21, indicated Client #2 said he/she was not always provided skilled nursing visits twice a day, and indicated Client #2 said there were times when a person unknown to him/her and not employed by the Agency would conduct visits. The Form indicated that Nurse #1 said that on 6/13/21 for the A.M., visit to Client #2’s home, he instructed a person unknown to and not employed by the Agency to see Client #2 and administer medication. During an interview on 10/27/21 at 3:01 P.M.; The Administrator said she did not know who Nurse #1 sent to Client #2's home to conduct that home visit. The Administrator said Nurse #1 did give them a name but said that person was not employed by the agency. The Administrator said she did not report the allegation or findings regarding a person unknown to and not employed by the Agency performing client visits to the Department of Public Health.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on records reviewed and interviews, for one of three clients (Client #1), the Agency failed to ensure they maintained a complete and accurate medical record. For Client #1 there was missing documentation related to his/her anticoagulant medication, monitoring, and labwork, and progress notes in July 2021 inaccurately documented Client #1 was hospitalized to justify why there were no home visits conducted on those days. Findings include: The Agency’s Policy, titled Skilled Visit Documentation, dated 3/2018, indicated the medical record would contain progress notes for each visit, which would include the signature of the staff member providing the service, the client’s vital signs and any other required measurement, and a current medication administration sheet that included the times of administration. Client #1 was admitted to the Agency in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated he/she was prescribed Coumadin, an anticoagulant medication which required regular blood labwork monitoring to ensure proper dosage. Review of Client #1’s medical record indicated there was no Medication Administration Records for the months of June 2021 or July 2021, and there was no documentation to support that his/her Coumadin levels were monitored or what his/her Coumadin lab results were. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. There was no documentation that Client #1 received any nursing visits on 7/10/21, and no documentation to support that Nurse #1 completed an assessment of a change in condition, or notification of a change in condition to Client #1’s physician. Review of Client #1’s medical record indicated there was a Physician’s Order, dated 7/07/21, that indicated he/she was transferred to the Hospital for evaluation on 7/07/21, and home visits were on hold. The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized on 7/07/21 through 7/09/21. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital, which was on 7/11/21, and offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. Nurse #1 said Client #1’s Coumadin labwork results should have been documented in his/her medical record in Nurse Progress Notes, and offered no explanation why there was no documentation to support the results in Client #1’s medical record. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said she had questioned Nurse #1 as to what day Client #1 had been admitted to the Hospital, and said Nurse #1 did not notify Nurse Manager #1 about the transfer until 7/11/21. The Administrator said Nurse #1 did not complete his documentation including assessment and reason for transfer to the Hospital, and said an exact date for Client #1’s transfer to the Hospital was never clarified between Nurse #1 and the Agency. The Administrator said she was not aware that Nurse #1 had not conducted skilled nursing visits from 7/07/21 through 7/10/21 until after Client #1 was admitted to the Hospital.

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 records reviewed and interviews, for one of three sampled Clients, (Client #1), the Agency failed to ensure a complete and accurate medical record was maintained, including accurate and complete Skilled Nurse Progress Notes. Client #1 was transferred to the Hospital on 7/11/21, however his/her medical record included Nurse Progress Notes that indicated he/she was hospitalized starting 7/07/21, however Client #1 was not admitted to the Hospital until 7/11/21. There was no documentation to support Client #1's Coumadin (anticoagulant medication that requires blood lab monitoring to ensure proper dosing), blood levels were monitored, and what the most current physician orders were for dosage for the months of June and July 2021. Findings include: The Agency’s Policy, titled Skilled Visit Documentation, dated 3/2018, indicated the medical record would contain progress notes for each visit, which would include the signature of the staff member providing the service, the client’s vital signs and any other required measurement, and a current medication administration sheet that included the times of administration. Client #1 was admitted to the Agency in August 2020, diagnoses included atrial fibrillation, dementia, depressive disorder, alcohol use, hypertension, long term use of anticoagulants (blood thinner), diabetes, and prosthetic heart valve. The Home Health Certification and Plan of Care, Certification Period dated 6/01/21 through 7/30/21, indicated Client #1 required Skilled Nursing visits twice daily for medication administration and review, and assessment of diabetes and anticoagulation. Review of Client #1’s medical record indicated he/she was prescribed Coumadin. Review of Client #1’s medical record indicated there was no Medication Administration Records for the months of June 2021 or July 2021, and there was no documentation to support that his/her Coumadin levels were monitored or what his/her Coumadin lab results were. Review of Client #1’s medical record indicated there were nurse progress notes dated 7/07/21, 7/08/21, and 7/09/21, two notes for each day, that indicated he/she was hospitalized and therefore skilled nursing visits were not performed. There was no documentation to support that Client #1 received any nursing visits on 7/10/21, and no documentation to support that Nurse #1 completed an assessment of a change in condition, or notification of a change in condition to Client #1’s physician. Review of Client #1’s medical record indicated there was a Physician’s Order, dated 7/07/21, that indicated he/she was transferred to the Hospital for evaluation on 7/07/21, and home visits were on hold. The Hospital History and Physical, dated 7/11/21, indicated Client #1 was transferred to and admitted to the Hospital on 7/11/21. This was not consistent with the Agency’s documentation that indicated Client #1 was hospitalized on 7/07/21 through 7/09/21. During an interview on 10/28/21 at 3:49 P.M., Nurse #1 said Client #1 was not hospitalized in the days leading up to his/her last admission to the Hospital (7/11/21), and offered no explanation why his documentation indicated Client #1 was in the Hospital from 7/07/21 through 7/09/21, or why there was no documentation for 7/10/21. Nurse #1 said Client #1 was sent to the Hospital Emergency Department on 7/11/21 due to a decline in condition. Nurse #1 said he did not document Client #1’s change in condition anywhere. Nurse #1 said Client #1’s Coumadin labwork results should have been documented in his/her medical record in Nurse Progress Notes, and said he could not explain why there was no documentation to support the results in Client #1’s medical record. During an interview on 10/27/21 at 9:30 A.M., and throughout the survey, the Administrator said Nurse #1 did not complete his documentation including assessment and reason for transfer to the Hospital, and said an exact date for Client #1’s transfer to the Hospital was never clarified between Nurse #1 and the Agency.