Every finding on record at Coastal Staff Relief Inc

A complaint investigation survey entrance conference was conducted on 04/27/2021 with the Alternate Administrator/ Supervising Nurse at 11:40 a.m. Census: L&CHHS: --- 119 LHHS: ------21 PAS------------0 Complaint #: 272261 An exit conference was conducted on 04/28/2021 with the Administrator and Alternate Administrator at 4:30 p.m. The preliminary findings were discussed. The Agency was in compliance with 42 CFR part 484.22 Emergency preparedness requirement for Home Health Agencies. Abbreviation: CFR - Code of Federal Regulations

A complaint investigation survey entrance conference was conducted on 04/27/2021 at 11:40 a.m. with the Alternate Administrator/ Supervising Nurse. Census: L&CHHS: --- 119 LHHS: ------21 PAS------------0 Complaint #: 272261 An exit conference was conducted on 04/28/2021 with the Alternate Administrator/Supervising Nurse at 4:30 p.m. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting an acceptable Plan of Correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations used: Admin - Administrator LHHS - License Home Health Services L&CHHS - License and Certified Home Health Services POC - Plan of Care SN - Skilled Nurse PT - Physical Therapy OT - Occupational Therapist OTA - Occupational Therapist Assistant Prn -Whenever needed RN - Registered Nurse Vs - Vital signs Bs - Blood sugar w- week

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record reviews and interviews the administrator failed to ensure the agency's skilled nurses conducted appropriate assessments and provided standardized care that met patients' needs during home visits for 2 of 3 (#1 & #2) patients whose electronic clinical records were reviewed. This failure could put agency's Patients at a high risk for substandard care that could lead to deteriorating health outcome or even death. Findings includes: Patient 1 Review of Patient #1's electronic clinical records revealed a (POC) for certification period 06/06/2020 - 08/04/2020 that showed a start of care date of 04/07/2020. The POC listed the Patient's primary diagnosis of Chronic Diastolic (congestive) Heart Failure and other pertinent diagnoses including Weakness, Pulmonary Hypertension, Unstable Angina, Diabetes type 2, Essential Hypertension. The POC also contained the following orders and Treatment for disciplines: Skilled Nurse: 2W3, 1W6 effective 06/07/2020 PT: Evaluate and treat starting from 06/07/2020 per physician's order. The POC also contained information that Patient was at risk for rehospitalization related to her principal diagnosis of congestive heart failure and development of respiratory disease due to the current COVID-19 pandemic. All staff were to conduct appropriate assessment during home visits and to notify Patient's physician with any health parameters such as Blood pressure, Heart rate, Temperatures, Body weight, and Oxygen saturation that were out of range. Further review of Patient's electronic clinical record revealed that Patient was readmitted to the hospital from 06/11/2020 -06/18/2020 for Congestive Heart failure exacerbation. Review of Agency's complaint log revealed a complaint from Patient #1 dated 05/27/2020. The complaint revealed that Patient had called the agency to report that her nurse staff E was not checking her vital signs during the home visits. The complaint document stated that Nurse E usually get his vital signs readings from the ones previously recorded vital signs that were assessed by Patient's privately paid Home Health Aide. The complaint document further stated that the same Nurse E came to visit Patient at another occasion and the Patient checked her own vital signs and the blood pressure was out of normal range, but the nurse wrote down a wrong blood pressure and did not call the Patient's physician to coordinate care regarding the out- of- range blood pressure. During interview with Patient #1 on 04/28/2021 at 9:28 a.m., the Patient told surveyor that another agency staff nurse E who used to visit her, did not always check her vital signs. Patient #1 reported that Staff E usually copied the Patient's vital signs from the vital signs that were previously recorded by the Patient's private duty Home Health Aide. And during one home visit she (Patient) checked her blood pressure and it was out of range the nurse he did call the doctor about the blood pressure issue but wrote down a wrong blood pressure value in the Patient blood pressure log and on his note. Patient #1 added that she finally called the agency and reported to someone and the Agency sent her another nurse. During interview with staff B on 04/28/2021 at 3:28 p.m. when asked about Patient #1's complaint about nurse E not conducting appropriate assessment of Patient's health status such as checking Patient's vital signs during home visits, Staff B stated that the Patient did call to complain about that and that she had asked the staff about that allegation and he denied it. Staff B added that the agency had removed him from Patient#1's case and reassigned another nurse. When asked if Staff E was still seeing agency Patients, Staff B said, "Yes." Interview with staff E on 04/28/2021 at 4:40 p.m. regarding Patient #1's allegation, he denied that he did not check Patient #1's vital signs, stating that he always checked the Patient's vital signs during all his visits. He also denied not calling the physician for a blood pressure that was out of range because Patient's blood was always within range. Review of the agency's policy document titled Care Planning Process ( and Comprehensive Assessment) reads in part, " ...Each patient must receive and an Agency must provide a patient-specific assessment ... Reassessment, which is a re-evaluation of patient's current status and healthcare needs occurs at each skilled visit ..." Patient #2 Review of Patient's electronic clinical record for certification period 01/14/2020 - 03/13/2020 revealed a (POC) a start of care date of 01/14/2020. The POC listed the primary diagnosis of Pneumonitis due to inhalation of food and vomit, with other diagnoses including Neoplasm of the pharynx, gastrostomy status. The POC orders for treatment included: SN 2w2, 1w7 - SN was to see Patient twice a week for two weeks and then once a week for 7 weeks. POC showed that Patient had a gastrostomy tube(G-tube) newly inserted for feeding and medication administration. Review of the Start of care assessment dated 01/14/2021 and signed by staff C revealed that Patient #2's initial weight was not assessed. Staff C documented presence of a gastrostomy tube inserted on Patient, but did not document the condition of the G-TUBE site in the assessment record. Interview with Patient #2's family member on 04/28/2021 at 9:46 a.m., she stated that Staff C did not open the bandage on the G- tube site to look at the condition of the skin around the area. The family member further stated that the therapist the agency sent out the initial time did not seem to know what he was doing because he was exercising Patient upper extremities instead of working on his throat muscles as was ordered by the Patient's physician (the order was for speech language Pathologist and not for physical therapy). During interview with the Alternate administrator / staff B on 04/28/2021 at 4:35 p.m., the above findings were presented to the staff and she stated that she was not aware that the staff C was not performing assessments as she should be doing. Surveyor requested to speak with staff C and was told she was no longer working with the Agency. Review of agency's Policy document titled "Care Planning Process and the Comprehensive Assessment" reads in part, " ...The comprehensive assessment must accurately reflect the Patient's status ... Each patient must receive, and an Agency must provide a patient-specific assessment ... Reassessment, which is a re-evaluation of patient's current status and healthcare needs occurs at each skilled visit ..."