Every finding on record at County of Hamilton

A Recertification Survey was conducted by the Department of Inspections and Appeals from 5/13/24 through 5/15/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 5/13/24 through 5/15/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a census of 64 current patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral for 2 of 7 sampled patients (Patients #1 and #5). Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: 2. Patient #6 had a start of care date of 3/6/24 and discharge date of 6/28/24. Review of the clinical record revealed the following: a. The POCs, dated 3/6/24 to 5/4/24, documented the patient had orders for skilled nurse and physical therapy visits. b. The referral, dated 2/29/24, included documentation of referral for services by the physician's clinic. c. The skilled nurse visit note at the start of care, dated 3/6/24, included documentation of the initial assessment visit. d. The clinical record failed to include documentation of a physician's order for services to start on 3/6/24. e. The agency failed to conduct the initial assessment within 48 hour after the physician's referral. The above findings shared with the Clinical Manager. The agency provided no further information prior to the end of the survey. The agency policy, Initial Visit and Comprehensive Assessment reviewed February 2018, revealed in pertinent part, the initial visit must be held within 48 of referral or within 48 hours of clients return to home or on the physician ordered start of care date. In an interview on 5/15/24 at 11:30 AM, the Clinical Manager reported she was unable to find a physician order to start home care services within 48 hours of Patient #1’s start of care date of 4/25/24. Patient #1 had a start of care date of 4/25/24 and received services from the agency. Clinical record review revealed the following: The physician's initial referral order, dated 4/19/24 and sent to the agency by facsimile (fax) on 4/19/24, ordered skilled nursing home health services but did not identify a specific start of care date. The Plan of Care (POC), dated 4/25/24 to 6/23/24, identified the start of care date was 4/25/ 24. Lacked documentation of any skilled nursing visit prior to 4/25/24 and lacked documentation of any case communication notes or notes in the electronic medical record (EMR) explaining the delay of the start of care. Lacked documentation of any follow up with the referring physician to report the delay in start of care. The clinical record lacked documentation of any physician' s order to delay the home health services. The patient was not admitted to service until 5 days after receiving the referral.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to comprehensively provide wound assessments for 1 of 1 sampled patients with wounds (Patient #1). Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency's policy, Assessment and Documentation of Wounds last reviewed July 2018, revealed in pertinent part, to document the following on the visit report: the treatment and condition of the wound (each visit), appearance of the wound, wound measurements (at least weekly) including the length, depth, and width of the wound in centimeters, depth and location of undermining in centimeters, skin around the wound, color, odor, and estimated amount of drainage, and compare the progress of the wound with the goals of therapy. Wound care is covered by Medicare as long as the need for skilled care and treatment is clearly and precisely documented on the visit report. In an interview on 5/15/24 at 11:30 AM, the Clinical Manager reported she was unable to find wound measurements for Patient #1’s wound for the week of 4/28/24. The Clinical Manager was able to find visit notes of wound assessment, but the wound assessments failed to include measurements. Patient #1 had a start of care date of 4/25/24 and received services from the agency. Clinical record review revealed the following: Orders that included skilled nursing visits for admission, then two visits per week for two weeks, then weekly visits. Each nursing visit was ordered to include wound treatment and dressing changes. The skilled nursing visits on 4/30/24 and 5/3/24 failed to include a comprehensive wound assessment with no wound measurements documented. The above findings were reviewed with the Clinical Manager and no further information provided prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, clinical record, agency policy, patient interview, and staff interview, the agency failed to include all required components of the Plan of Care (POC) for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5, and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. Findings include: 4. Patient #4 had a start of care date of 4/19/24. Clinical review revealed the following: a. The POC, dated 4/19/24 to 6/17/24, included the following DME: Shower chair, hospital bed, front-wheeled walker, 4 x 4 split gauze, IV pole, peg tube supplies, urinal, wheelchair, scale and commode. b. The skilled nurse visit note at the start of care, dated 4/19/24, included documentation the patient used the DME ramp, mepilex dressing, medication planner and gait belt. The POC failed to include the patient's DME use of a ramp, mepilex dressing, medication planner and gait belt. 5. Patient #5 had a start of care date of 8/15/23. Clinical review revealed the following: a. The POC, dated 4/12/24 to 6/10/24, included the following DME: cane, 4 wheeled walker, bed rail, shower grab bars, shower chair, med planners, toilet seat riser, dentures, eye glasses, hearing aids and lift reclining chair. b. The skilled nurse visit note, dated 3/12/24, included documentation the patient used the DME medication planner. The POC failed to include the patient's DME use of a medication planner. 6. Patient #7 had a start of care date of 1/3/21. Clinical review revealed the following: a. The POC, dated 4/28/23 to 6/26/23 and 6/27/23 to 8/25/23, included orders for skilled nursing services. b. The clinical record included a copy of the patient's advanced directives, dated 9/30/20. The POC failed to include the patient's advanced directives. The above findings shared with the Clinical Manager. The agency failed to provide additional information prior to the end of the survey. Agency policy, titled Care Planning, Coordination of Services, and Quality Care dated January 2018, revealed in pertinent part, that each client must receive the home health services that are written in an individualized plan of care that must include the following: types of services, supplies, and equipment required, information related to any advance directives, and any additional items HCPH (Hamilton County Public Health) or the physician may choose to include. In an interview on 5/15/24 at 10:15 AM, the Clinical Manager reported that she was not sure why the POC’s did not show the advance directive status. The Clinical Manager asked the nurses, who all reported they are discussing advanced directives with patients at admission, but will need to look into the electronic health record (EHR) system the agency uses to determine the cause of the lack of this entry on the POC. During the same interview, when asked about Patient #1’s medication reconciliation at admission, the Clinical Manager requested assistance in understanding how to perform medication reconciliation at admission when the agency has a medication list on file and the agency has a medication list included with the referral. 1. Patient #1 had a start of care date of 4/25/24 and received services from the agency. In a concurrent observation and interview with the patient on 5/14/24 at 1:30 PM, disposable briefs were observed in the patient’s bathroom. The patient reported he started wearing them prior to starting home health care and wears the disposable briefs all of the time for incontinence. The patient reported discussion regarding advance directives occurred with his admission to home health care and that full code was his result of this discussion. Medications were reviewed with the patient finding the patient reporting that no longer takes furosemide (to remove excess fluid). The patient reported he was ordered to take furosemide at the clinic visit that his doctor ordered home health. The patient reported he no longer took lisinopril (treats high blood pressure), that he stopped taking that a year ago when he had a hip replacement procedure and had home health care. Ciclopirox (prescription topical solution to treat nail fungus) was observed next to his other medications, the date it was filled on the medication label was c4/17/24, the patient reported he took that medication prior to starting home care and takes the medication as prescribed. Clinical record revealed: a. The Summary of Care sent via facsimile (fax) with referral documents from the referring clinic on 4/19/24 included a medication that included ciclopirox and did not lisinopril. b. The POC from 4/25/24 to 6/23/24 did not have any documentation in the advance directive area, did not list incontinence supplies in the durable medical equipment section, included lisinopril, and did not list ciclopirox. 2. Patient #2 had a start of care date of 12/1/23 and received services from the agency. In a concurrent observation and interview with the patient on 5/14/24 at 8:45 AM, when asked if the patient wore incontinence products, she replied that she has worn a pad for over a year for incontinence. When asked if she used a Cpap (continuous positive airway pressure) or BiPap (bilevel positive airway pressure) to treat obstructive sleep apnea, the patient reported that she has used a BiPAP for over a year. The patient reported discussion regarding advance directives occurred with her admission to home health care and she was undecided as to whether or not she would like to be a full code or a DNR (do not resuscitate). Medications were reviewed with the patient finding the patient reporting that she did not know she was ordered to take amoxicillin 1 hour prior to a procedure as a result of the knee replacement she had in October 2023. The patient reported she had postoperative complications and had a challenging time managing her health needs. The patient reported to Staff D, Registered Nurse (RN), that she was no longer taking benzonatate, she had this medication refilled a few times, but she no longer had the cough she needed the medication for. The 4/18/24 was the date last filled on the medication label for benzonatate. Clinical record review revealed: a. The POC from 3/30/24 to 5/28/24 did not have any documentation in the advance directive section, did not list incontinence supplies or BiPap in the DME section, and did not list benzonatate or amoxicillin. b. The POC included the patient’s diagnoses of generalized anxiety disorder and obstructive sleep apnea, that the patient has outpatient psychiatric services, and that the patient’s mental statuses included depression and schizophrenic disorder. 3. Patient #3 had a start of care date of 2/2/24 and received services from the agency. In a concurrent observation and interview with the patient on 5/13/24 at 3:15 PM, when asked if the patient wore incontinence products, she replied that she has worn a pad for over a year for incontinence. When asked if she has any allergies, the patient reported that she has one allergy to scented soaps. The patient reported discussion regarding advance directives occurred with her admission to home health care and DNR (do not resuscitate) was her advance directive Medications were reviewed with the patient finding the patient reporting that she was unable to keep her lidocaine patch in place, that it wouldn’t stick and move, the patient obtained a prescription for lidocaine gel in October 2023, has refilled the medication several times, and uses the medication. The agency medication list included orders for a bedtime dose of lorazepam (treats anxiety), the patient reported she no longer took this dose because at her hospitalization she was prescribed temazepam to take instead. During review of temazepam, it was discovered that the agency medication list contained a 15 milligram (mg) dose and the medication bottle label dose was 22.5 mg. The patient reported that temazepam 15 mg was originally prescribed while hospitalized and then at a follow up clinical visit, the medication was increased to 22.5 mg. Clinical record revealed: The POC from 4/2/24 to 5/31/24 did not have any documentation in the advance directive section, did not include documentation in the allergy section, did not list incontinence supplies in the DME section, and the medication list did not include lidocaine gel, the updated dosing for lorazepam or temazepam.

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 agency policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 7 sampled patients (Patients #4 and #7). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Care Planning, Coordination of Services and Quality Care, dated 1/2018, drugs, services and treatments are administered only as ordered by the physician. 1. Patient #4 had a start of care date of 4/19/24. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/19/24 to 6/17/24, documented the patient had nutritional requirements of a general diet and percutaneous endoscopic gastrostomy (PEG) tub supplemental feeding. The Plan lacked any orders for supplemental feeding, formula, amount or rate of administration. b. The skilled nurse visit note on admission, dated 4/19/24, included documentation the patient had feedings of Nestle Nutren 1.5 through the PEG tube by gravity. The clinical record lacked physician orders for PEG tube formula, amount or rate of administration. 2. Patient #7 had a start of care date of 1/3/21 and discharge date of 6/29/23. Review of the clinical record revealed the following: a. The POCs, dated 2/27/23 to 4/27/23, 4/28/23 to 6/26/23 and 6/27/23 to 8/25/23, documented the patient had orders for skilled nurse visits to set up medications in a medication planner. The orders included the medication Belsomra to aide in sleep. b. The skilled nurse visit note, dated 2/3/23, included documentation the nurse set up medications for the patient for 10 day supply. Belsomra called into the pharmacy for refills. c. The visit report, dated 2/4/23, included documentation a phone call made to the on call nurse by the patient. The patient identified he/she hurt his/her eye and had been having bad post traumatic stress disorder (PTSD) last night and today. He/she stated he/she would quit taking medications until a nurse will come look at his/her medications. d. The skilled nurse visit report, dated 2/4/23, revealed a visit made to the patient's home and set up medications for 3 days for the remaining weekend. c. During an interview on 5/15/34 at 8:50 AM, Staff D, RN stated she was the nurse on call and received a call from the patient. The patient upset about the medications not set up correctly and the sleeping medication not in the medication planner. She stated she made a visit to the patient's home and found the medication Belsomra not in the medication box for Saturday, Sunday, Monday, Tuesday, Wednesday or Thursday but were in the following weekend for Friday Saturday and Sunday holders instead. She further stated she took all of the medications out of the medication planner for the week and re-set up the medications for the weekend. She placed the sleeping medication in the planner for Saturday, Sunday and Monday. The sleeping medication had been requested for a refill and would set up the remaining medications on Monday. The agency failed to provide medication set up according to physician orders. The above findings were reviewed with the Clinical Manager. The agency provided no further information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 2 sampled patients receiving home health aide services (Patients #4 and #5). The agency reported 38 patients who received home health aide services. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to the agency policy, titled Home Health Aide Services, dated 3/20/24, home health aides are assigned to specific clients by a registered nurse or other appropriate skilled professional, with written client care instructions for a home health aide prepared by the registered nurse or other appropriate skilled professional. 1. Patient #4 had a start of care date of 4/19/24. The Plans of Care, dated 4/19/24 to 6/17/24, included physician orders for skilled nursing services for assessment every other week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan for the months of March, April and May included direction to the aide to perform the following: Clean tub/shower, dressing change, help with dressing, shave, shower bath, skin care lotion to extremities and topical application Calmoseptine to peri area of peg at each visit after shower. b. Home health aide visit notes, dated 4/24, 4/30, 5/2, 5/7 and 5/9/24, failed to include documentation the aide performed the task of shaving and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 2. Patient #5 had a start of care date of 8/15/23. The POCs, dated 2/12/24 to 4/11/24 and 4/12/24 to 6/10/24, included physician orders for skilled nursing services for assessment every other week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan for the months of March, April and May included direction to the aide to perform the following: exercise program, help with dressing, help with walking, shower bath, skin care lotion to arms, legs and back and topical application Nystatin to groin. b. Home health aide visit notes, dated 3/22, 3/26, 3/29, 4/2, 4/5, 4/26, 4/30 and 5/3/24, failed to include documentation the aide performed the task of exercise program and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Clinical Manager. The agency failed to provide additional prior to the end of the survey.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 2 of 2 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patients #4 & #5). The agency reported 29 patients who received home health aide services with every 14 day supervision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency's policy titled Home Health Aide Services, dated 3/20/24, when home health aide services are provided to a client who is receiving skilled nursing, a registered nurse or other appropriate skill professional who is familiar with the client, the clients plan of care and the written client instructions must make a supervisor visit to the client's home one every 14 days. During an interview on 5/14/24 at 8:24 AM the Clinical Manager stated the nurse completes aide supervision and documents under the episode tab. 1. Patient #4 had a start of care date of 4/19/24. The Plan of Care (POC), dated 4/19/24 to 6/17/24, included physician orders for skilled nursing and home health aide services. Review of the clinical record included the following: a. The supervision report, dated 4/25/24, included documentation of home health aide supervision. b. Review of the clinical record on 5/13/24, lacked additional documentation of home health aide supervision (2 days late). The agency failed to provide home health aide supervision every 14 days. 2. Patient #5 had a start of care date of 4/19/24. The POCs, dated 2/12/24 to 4/11/24 and 4/12/24 to 6/10/24, included physician orders for skilled nursing and home health aide services. Review of the clinical record included the following: a. The supervision report, dated 2/28/24, included documentation of home health aide supervision. b. The supervision report, dated 4/9/24, included documentation of home health aide supervision (27 days late). c. Review of the clinical record lacked additional documentation of home health aide supervision. The agency failed to provide home health aide supervision every 14 days The above information were reviewed with the Clinical Manager. No additional information provided prior to the end of the survey.

A complaint investigation, dated 10/14/21 to 10/21/21, for complaint number 47716-C identified the following: During the survey, the surveyors identified an Immediate Jeopardy situation. The home health agency failed to do the following under the Condition of Participation 42 CFR 484.50 Patient Rights: 1) failed to determines under policy set by the agency of addressing discharge for cause (G462) 2) failed to advise the patient, representative, the physician issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency that a discharge for cause is being considered (G464) 3) failed to make efforts to resolve the problems presented by the patient's behavior, the behavior of other persons in the patient's home, or situation (G466) 4) failed to document the problem and efforts made to resolve the problem and enter this documentation into its clinical records (G470) The home health agency abated the Immediate Jeopardy situation 10/21/21 at 1:30 PM. The agency was operating out of compliance with the Condition of Participation 42 CFR 484.50: Patient Rights as well as having deficient practices in the following standard level hospice regulations. As a result of the agency's non-compliance with federal Conditions of Participation, the agency and its registered nurses are prohibited from providing basic home health aide skills competency training and from providing both written and demonstrated basic skills competency evaluation for all newly hired home health aides for a period of 2 years, beginning on 10/21/21 and ending on 10/21/23. The complaint related to 484.50 Patient Rights was substantiated; The complaint related to 484.60 Care Planning Coordination and Quality of Care was substantiated; The complaint related to 484.80 Home Health aide services was substantiated.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on surveyor observation, record review, policy review and staff interview, the home health agency: 1) failed to determines under policy set by the agency of addressing discharge for cause (G462) 2) failed to advise the patient, representative, the physician issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency that a discharge for cause is being considered (G464) 3) failed to make efforts to resolve the problems presented by the patients behavior, the behavior of other persons in the patient's home, or situation (G466) 4) failed to document the problem and efforts made to resolve the problem and enter this documentation into its clinical records (G470) The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 61 current patients.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to document the patient's behaviors and circumstances that warranted patient's discharge for cause and the agency's efforts to resolve the problems prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #3) The agency reported a current census of 61 patients. The agency reported discharging 27 patients between 7/27/2021 and 10/8/2021.Failure to document the patient's behaviors and circumstances that warranted patient's discharge prevented the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include:According to the agency policy titled Patient Bill of Rights, dated 9/14/2020, each patient has the right to express grievances regarding treatment or care that is furnished or failed to be furnished, or lack of respect for property and/or person by anyone who is furnishing services on behalf of the home care agency. Patient's, family or designees will not be subject to reprisal or discrimination if complaints are made. Patients have the right to receive proper written notice, in advance of a specific service being furnished, if the Home Health Agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. According to the agency policy titled Policy Clients Rights, dated1/2018, clients have the right to make complaints to the agency about treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who's furnishing services on behalf of the agency. The client and their representative (if any) have a right to be informed of the agency policy for transfer and discharge.According to the agency policy titled Complaints, dated 5/2021, the client or client's representative may formally make a complaint regarding the following topics but this is not an exhausted list: treatment or care that is or failed to be furnished, is furnished inconsistently, or is furnished inappropriately; mistreatment, neglect, or verbal mental sexual and physical abuse, including injuries of unknown origin,, and or misappropriation of client property by anyone providing services of behalf of the agency. According to the agency policy titled Discharge for Cause, dated 1/13/18, documentation in the clinical record should include: description of the behaviors and circumstances encounter, assessment of the situation, communication with the agency management and the physician responsible for the plan of care, efforts and plan to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, results of the plan implementation and names and contact numbers for referral resources provided. Advise the patient representative (if any), the physician issuing orders for plan of care, the primary care ; physician or other healthcare professional who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered. In situations when staff are threatened or endangered, the home health agency may be required to take immediate actions to discharge or transfer the patient without taking measures to resolve the issue.1. Patient #3 had a start of care date of 10/16/2020 and was discharged by the agency on 10/7/2021.Clinical record review and associated patient and staff interviews included the following:a. The Plans of Care (POC), dated 6/13/2021 to 8/11/2021 and 8/12/2021 to 10/10/2021, included physician orders for skilled nurse visits every other week to assess vital signs and physical assessment. The POC also included physician orders for home health aide 3 times a week to assist with personal cares, showering/bathing and skin care.b. The physician's nurses note, dated 10/7/2021, identified the patient discharged from services with the agency. There was a Department of Human Services (DHS) report filed against the agency care providers for adult abuse/neglect. The agency had discontinued all of their services and notified the patient and family. c. On 10/6/2021, Agency staff were notified that a Dependent Adult Abuse Report was filed regarding the agency. The agency written notification to the patient, dated 10/7/2021, identified the agency discharged the patient for cause, immediately. The written notification included the Dependent Adult Abuse Report has created a threatening, hostile and non-therapeutic work environment and we will not be able to continue to work with you. This information delivered to you by phone, October 7, 2021.d. The discharge summary, dated 10/20/2021, documented the patient discharge per agency policy.e. During agency staff interview on 10/19/2021 at 9:00 AM, Staff C, Registered Nurse (RN), reported she did routinely see Patient #3 every other week. On 10/6/2021 she had a missed call form DHS. She stated she spoke with DHS with the Administrator and Clinical Manager present. After the report no further services were provided. Per the agency policy the agency decided services were cancelled. She stated the patient discharge for harassing and did not feel threatened beyond the DHS report and the personal use of her name and telephone number. She didn't want to go back in the home if not happy with the services. During patient interview on 10/19/2021 at 10:35 AM, he/she stated the agency called and told him/her that no services would be provided anymore. The agency never came back. f. During agency staff interview on 10/19/2021 at 3:45 PM, Staff D, Home Care Aide (HCA), reported she assisted the patient 3 times a week. On October 6, 2021 she had received a call from DHS and reported it to the Clinical Manager. The agency office staff handled the situation after that. She further stated she did tell the agency she would not feel comfortable going back to the patient's home. It was the only situation she had in the home. g. The clinical record lacked documentation of the patient's behaviors and circumstances that warranted patients' discharge. The above findings for Patient #3 were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to notify the patient or the physician prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #3) The agency reported a current census of 61 patients. The agency reported discharging 27 patients between 7/27/2021 and 10/8/2021. Failure to provide patient's or their physician with notification that discharge for cause is being considered denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include:According to the agency policy titled Patient Bill of Rights, dated 9/14/2020, each patient has the right to express grievances regarding treatment or care that is furnished or failed to be furnished, or lack of respect for property and/or person by anyone who is furnishing services on behalf of the home care agency. Patient's, family or designees will not be subject to reprisal or discrimination if complaints are made. Patients have the right to receive proper written notice, in advance of a specific service being furnished, if the Home Health Agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. According to the agency policy titled Policy Clients Rights, dated1/2018, clients have the right to make complaints to the agency about treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who's furnishing services on behalf of the agency. The client and their representative (if any) have a right to be informed of the agency policy for transfer and discharge.According to the agency policy titled Complaints, dated 5/2021, the client or client's representative may formally make a complaint regarding the following topics but this is not an exhausted list: treatment or care that is or failed to be furnished, is furnished inconsistently, or is furnished inappropriately; mistreatment, neglect, or verbal mental sexual and physical abuse, including injuries of unknown origin,, and or misappropriation of client property by anyone providing services of behalf of the agency. According to the agency policy titled Discharge for Cause, dated 1/13/18,documintation in the clinical record should include: description of the behaviors and circumstances encounter, assessment of the situation, communication with the agency management and the physician responsible for the plan of care, efforts and plan to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, results of the plan implementation and names and contact numbers for referral resources provided. Advise the patient representative (if any), the physician issuing orders for plan of care, the primary care ;physician or other healthcare professional who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered. In situations when staff are threatened or endangered, the home health agency may be required to take immediate actions to discharge or transfer the patient without taking measures to resolve the issue.1. Patient #3 had a start of care date of 10/16/2020 and was discharged by the agency for cause on 10/7/2021. Clinical record review and associated patient and staff interviews included the following:a. The Plans of Care (POC), dated 6/13/2021 to 8/11/2021 and 8/12/2021 to 10/10/2021, included physician orders for skilled nurse visits every other week to assess vital signs and physical assessment. The POC also included physician orders for home health aide 3 times a week to assist with personal cares, showering/bathing and skin care.b. The physician's nurses note, dated 10/7/2021, identified the patient discharged from services with the agency. There was a Department of Human Services (DHS) report filed against the agency care providers for adult abuse/neglect. The have pulled all of their services and notified the patient and family. c. On 10/6/2021, Agency staff were notified that a Dependent Adult Abuse Report was filed regarding the agency. The agency written notification to the patient, dated 10/7/2021, identified the agency discharged the patient for cause, immediately. The written notification included the Dependent Adult Abuse Report has created a threatening, hostile and non-therapeutic work environment and we will not be able to continue to work with you. This information delivered to you by phone, October 7, 2021. d. The discharge summary, dated 10/20/2021, documented the patient discharge per agency policy.e. During agency staff interview on 10/19/2021 at 9:00 AM, Staff C, Registered Nurse (RN), reported she did routinely see Patient #3 every other week. On 10/6/2021 she had a missed call form DHS. She stated she spoke with DHS with the Administrator and Clinical Manager present. After the report no further services were provided. Per the agency policy the agency decided services were cancelled. She stated the patient discharge for harassing and did not feel threatened beyond the DHS report and the personal use of her name and telephone number. She didn't want to go back in the home if not happy with the services. f. During agency staff interview on 10/19/2021 at 3:45 PM, Staff D, Home Care Aide (HCA), reported she assisted the patient 3 times a week. On October 6, 2021 she had received a call from DHS and reported it to the Clinical Manager. The agency office staff handled the situation after that. She further stated she did tell the agency she would not feel comfortable going back to the patient's home. It was the only situation she had in the home.g. The patient's clinical record lacked documentation of notification of the patient or his.her physician that discharge for cause being considered.The above findings for Patient #3 were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #3) The agency reported a current census of 61 patients. The agency reported discharging 27 patients between 7/27/2021 and 10/8/2021.Failure to attempt to initiate any efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include:According to the agency policy titled Patient Bill of Rights, dated 9/14/2020, each patient has the right to express grievances regarding treatment or care that is furnished or failed to be furnished, or lack of respect for property and/or person by anyone who is furnishing services on behalf of the home care agency. Patient's, family or designees will not be subject to reprisal or discrimination if complaints are made. Patients have the right to receive proper written notice, in advance of a specific service being furnished, if the Home Health Agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. According to the agency policy titled Policy Clients Rights, dated1/2018, clients have the right to make complaints to the agency about treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who's furnishing services on behalf of the agency. The client and their representative (if any) have a right to be informed of the agency policy for transfer and discharge.According to the agency policy titled Complaints, dated 5/2021, the client or client's representative may formally make a complaint regarding the following topics but this is not an exhausted list: treatment or care that is or failed to be furnished, is furnished inconsistently, or is furnished inappropriately; mistreatment, neglect, or verbal mental sexual and physical abuse, including injuries of unknown origin,, and or misappropriation of client property by anyone providing services of behalf of the agency. According to the agency policy titled Discharge for Cause, dated 1/13/18,documintation in the clinical record should include: description of the behaviors and circumstances encounter, assessment of the situation, communication with the agency management and the physician responsible for the plan of care, efforts and plan to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, results of the plan implementation and names and contact numbers for referral resources provided. Advise the patient representative (if any), the physician issuing orders for plan of care, the primary care ;physician or other healthcare professional who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered. In situations when staff are threatened or endangered, the home health agency may be required to take immediate actions to discharge or transfer the patient without taking measures to resolve the issue.1. Patient #3 had a start of care date of 10/16/2020 and was discharged by the agency for cause on 10/7/2021. Clinical record review and associated patient and staff interviews included the following:a. The Plans of Care (POC), dated 6/13/2021 to 8/11/2021 and 8/12/2021 to 10/10/2021, included physician orders for skilled nurse visits every other week to assess vital signs and physical assessment. The POC also included physician orders for home health aide 3 times a week to assist with personal cares, showering/bathing and skin care.b. The physician's nurses note, dated 10/7/2021, identified the patient discharged from services with the agency. There was a Department of Human Services (DHS) report filed against the agency care providers for adult abuse/neglect. The have pulled all of their services and notified the patient and family. c. On 10/6/2021, Agency staff were notified that a Dependent Adult Abuse Report was filed regarding the agency. The agency written notification to the patient, dated 10/7/2021, identified the agency discharged the patient for cause, immediately. The written notification included, the Dependent Adult Abuse Report has created a threatening, hostile and non-therapeutic work environment and we will not be able to continue to work with you. This information delivered to you by phone, October 7, 2021. d. The discharge summary, dated 10/20/2021, documented the patient discharge per agency policy.e. During agency staff interview on 10/19/2021 at 9:00 AM, Staff C, Registered Nurse (RN), reported she did routinely see Patient #3 every other week. On 10/6/2021 she had a missed call form DHS. She stated she spoke with DHS with the Administrator and Clinical Manager present. After the report no further services were provided. Per the agency policy the agency decided services were cancelled. She stated the patient discharge for harassing and did not feel threatened beyond the DHS report and the personal use of her name and telephone number. She didn't want to go back in the home if not happy with the services. f. During agency staff interview on 10/19/2021 at 3:45 PM, Staff D, Home Care Aide (HCA), reported she assisted the patient 3 times a week. On October 6, 2021 she had received a call from DHS and reported it to the Clinical Manager. The agency office staff handled the situation after that. She further stated she did tell the agency she would not feel comfortable going back to the patient's home. It was the only situation she had in the home.g. The patient's clinical record lacked documentation of any efforts made to resolve the problem prior to discharge. The above findings for Patient #3 were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #3) The agency reported a current census of 61 patients. The agency reported discharging 27 patients between 7/27/2021 and 10/8/2021.Failure to document the problems and efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. Findings include:According to the agency policy titled Patient Bill of Rights, dated 9/14/2020, each patient has the right to express grievances regarding treatment or care that is furnished or failed to be furnished, or lack of respect for property and/or person by anyone who is furnishing services on behalf of the home care agency. Patient's, family or designees will not be subject to reprisal or discrimination if complaints are made. Patients have the right to receive proper written notice, in advance of a specific service being furnished, if the Home Health Agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. According to the agency policy titled Policy Clients Rights, dated1/2018, clients have the right to make complaints to the agency about treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who's furnishing services on behalf of the agency. The client and their representative (if any) have a right to be informed of the agency policy for transfer and discharge.According to the agency policy titled Complaints, dated 5/2021, the client or client's representative may formally make a complaint regarding the following topics but this is not an exhausted list: treatment or care that is or failed to be furnished, is furnished inconsistently, or is furnished inappropriately; mistreatment, neglect, or verbal mental sexual and physical abuse, including injuries of unknown origin,, and or misappropriation of client property by anyone providing services of behalf of the agency. According to the agency policy titled Discharge for Cause, dated 1/13/18,documintation in the clinical record should include: description of the behaviors and circumstances encounter, assessment of the situation, communication with the agency management and the physician responsible for the plan of care, efforts and plan to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation, results of the plan implementation and names and contact numbers for referral resources provided. Advise the patient representative (if any), the physician issuing orders for plan of care, the primary care ;physician or other healthcare professional who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered. In situations when staff are threatened or endangered, the home health agency may be required to take immediate actions to discharge or transfer the patient without taking measures to resolve the issue.1. Patient #3 had a start of care date of 10/16/2020 and was discharged by the agency for cause on 10/7/2021. Clinical record review and associated patient and staff interviews included the following:a. The Plans of Care (POC), dated 6/13/2021 to 8/11/2021 and 8/12/2021 to 10/10/2021, included physician orders for skilled nurse visits every other week to assess vital signs and physical assessment. The POC also included physician orders for home health aide 3 times a week to assist with personal cares, showering/bathing and skin care.b. The physician's nurses note, dated 10/7/2021, identified the patient discharged from services with the agency. There was a Department of Human Services (DHS) report filed against the agency care providers for adult abuse/neglect. The have pulled all of their services and notified the patient and family. c. On 10/6/2021, Agency staff were notified that a Dependent Adult Abuse Report was filed regarding the agency. The agency written notification to the patient, dated 10/7/2021, identified the agency discharged the patient for cause, immediately. The written notification included the Dependent Adult Abuse Report has created a threatening, hostile and non-therapeutic work environment and we will not be able to continue to work with you. This information delivered to you by phone, October 7, 2021.d. The discharge summary, dated 10/20/2021, documented the patient discharge per agency policy.e. During agency staff interview on 10/19/2021 at 9:00 AM, Staff C, Registered Nurse (RN), reported she did routinely see Patient #3 every other week. On 10/6/2021 she had a missed call form DHS. She stated she spoke with DHS with the Administrator and Clinical Manager present. After the report no further services were provided. Per the agency policy the agency decided services were cancelled. She stated the patient discharge for harassing and did not feel threatened beyond the DHS report and the personal use of her name and telephone number. She didn't want to go back in the home if not happy with the services. f. During agency staff interview on 10/19/2021 at 3:45 PM, Staff D, Home Care Aide (HCA), reported she assisted the patient 3 times a week. On October 6, 2021 she had received a call from DHS and reported it to the Clinical Manager. The agency office staff handled the situation after that. She further stated she did tell the agency she would not feel comfortable going back to the patient's home. It was the only situation she had in the home.g. The patient's clinical record lacked documentation of any problems and efforts made to resolve the problem prior to discharge. The above findings for Patient #3 were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

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 clinical record review and agency staff interview, the agency failed to obtain physician orders for the addition of over-the-counter medications to the patient's medication regimen for 3 of 4 sampled patients (Patient's #1, #2 & #3). The agency reported a current census of 61 patients. Failure to ensure staff obtain physician orders for administration of medications provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy titled, Care Planning and Coordination of Services and Quality Care, dated 1/2018, drugs, services and treatments are administered only as ordered by the physician. 1. Patient #1 had a start of care date of 9/30/20. The Plan of Care, dated 7/27/21 to 9/24/21 and 9/25/21 to 11/23/21, included physician orders for skilled nursing services 1 time a week. The POC also included an order for dressing change to the lower right leg, cover with non-adhesive dressing an secure with gauze and an prothrombin time ratio (INR) laboratory test the week of 10/11/21. The Emergency Department Provider Notes, dated 8/27/21, identified the patient had a history significant for chronic venous stasis of the bilateral lower legs. The right leg appeared worse than the left and had signs of infection. The Physician orders dated 9/30/21 included the order for dressing changes for the right and left lower leg by placing Aquasol AG to the wound bed covering with Hydrofera Blue and dressing. The skilled nurse visit note dated 9/1, 9/20 and 10/5/21, lacked documentation of a dressing change as ordered by the physician. Review of the medical record lacked documentation of a laboratory draw for INR. During an interview with agency staff on 10/18/21 at 2:58 PM, the Administrator stated wound care orders may be faxed to the agency or called in. All orders should be entered into the electronic medical record. During an interview with agency staff on 10/18/21 at 3:03 PM, the Clinical Manager stated the outpatient treatment ordered for lymphedema and the agency did not see the order in the electronic medical record but located the order in the hard chart. 2. Patient #2 had a start of care date of 6/4/21. The Plan of Care, dated 10/5/21 to 12/3/21, included physician orders for skilled nursing services 1 time a week. The POC identified the patient's medical equipment included oxygen supplies. The update to the Comprehensive Assessment, dated 8/6/21 and 10/1/21, identified the patient had a fall risk due to oxygen tubing. The skilled nurse visit notes, dated 8/13, 8/19, 8/26, 9/1, 9/10, 9/17, 9/24, 10/8 and 10/15/21, identified the patient utilized oxygen via nasal canula. The clinical record lacked physician orders for oxygen. 3. Patient #3 had a start of care date of 10/16/2020 and a discharge date of 10/7/2021. The Plan of Care, dated 6/13/21 to 8/11/21 and 8/12/21 to 10/10/21, included physician orders for a skilled nursing services every other week. The skilled nursing visit note, dated 6/30/21, identified the presence of a rash to the forearms bilaterally and right side of the hip area, which was itchy and had been present for approximately 2 weeks. The patient had been applying cortisone cream to these areas and the patient reported it seemed to be improving. The telephone encounter, dated 7/14/21, revealed the physician was notified of the patient's rash on the right hip, right thigh and bilateral forearms. The rash was fine, prickly and red and itchy. A new physician order included to monitor the areas and continue the cortisone cream. The clinical record lacked documentation of physician order for cortisone prior to 7/14/21. In an interview on 10/19/2021 at 1:45 PM, the Clinical Manager, reported the physician order for cortisone received on 7/14/21 when she provided a skilled nurse visit at the patient's home. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to report changes in patient clinical findings to the physician for 2 of 4 sampled patients (Patient #7). The agency reported a census of 61 patients at the time of the survey. Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled, Care Planning and Coordination of Services and Quality Care, dated 1/2018, staff must assure communication with all physicians involved with the plan of care. 1. Patient #2 had a start of care date of 6/4/21. The Plan of Care (POC), dated 10/5/21 to 12/3/21, included physician orders for skilled nursing services 1 time a week. The skilled nursing visit note, dated 10/8/21, identified the patient had a fall and sustained a new skin tear and bruise. The clinical record lacked documentation the physician notified of the fall, skin tear and bruise. 2. Patient #3 had a start of care date of 10/16/2020 and a discharge date of 10/7/2021. The Plan of Care, dated 6/13/21 to 8/11/21 and 8/12/21 to 10/10/21, included physician orders for skilled nursing services every other week. The skilled nursing visit note, dated 6/30/21, identified the presence of a rash to the forearms bilaterally and right side of the hip area, which was itchy and had been present for approximately 2 weeks. The patient had been applying cortisone cream to these areas and the patient reported it seemed to be improving. The telephone encounter, dated 7/14/21, revealed the physician was notified of the patient's rash on the right hip, right thigh and bilateral forearms. The rash was fine, prickly and red and itchy. A new physician order included to monitor the areas and continue the cortisone cream. The clinical record lacked documentation of physician notification of the new rash areas prior to 7/14/21. In an interview on 10/19/2021 at 1:45 PM, the Clinical Manager, reported the physician was notified of the rash on 7/14/21 when she completed a skilled nurse visit at the patient's home. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on clinical record review, personnel file review, patient and staff interview, the agency failed to ensure 3 of 3 sampled home health aides (Staff D, E and F), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 2 sampled patients (Patient #3) with home health aide services, had documented evidence of competency by a registered nurse in the assigned task area prior to independently and performing the task with a patient. The agency reported a current census of 61 patients at the time of the survey, including 41 patients receiving home health aide (HHA) services. Failure to ensure home health aides successfully complete a competency evaluation in all basic home health aide skills on a patient and failure to ensure aides were competent in any assigned extra skills which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. The Medicare Conditions of Participation require home health agencies to determine competence of home health aides in those skills which exceed the 13 general basic home health aide skills areas prior to assigning the home health aide to a patient who would require the task to be performed. According to the agency's Policy titled Home Health Aide Services, dated 1/2018, any other task that the agency may choose to have an aide perform permitted under state law. The agency will train the HHA on any task not included in the original task list. The RN will provide documentation of skills training and this will be kept in the personnel file. Patient #3 had a start of care date of 10/16/20. The Plan of Care (POC), dated 8/12/21 to 10/10/21, included physician orders for skilled nursing and home health aide services. The home health aide care plan, dated 4/19/19, included registered nurse (RN) instructions to the aide to complete the assigned tasks of bathing and dressing the patient. Staff D, Home Health Aide, and Staff F, Home Health Aide independently provided home health aide services to patient #3. During a patient interview on 10/19/21 at 10:35 AM, the patient reported the home health aides applied ointment to the patient's rash and apply AFO (ankle/foot orthosis) braces. On 10/19/21 at 3:45 PM, during an interview, Staff D, Home Health Aide, reported she had been applying ointments and AFOs. Staff D, Home Health Aide, had a hire date of 10/12/20. The Home Health Aide's personnel file lacked documentation she had completed a competency evaluation for the task of applying ointments and AFO braces. Staff F, Home Health Aide, had a hire date of 10/12/20. The Home Health Aide's personnel file lacked documentation she had completed a competency evaluation for the task of applying ointments and AFO braces. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 2 sampled patients receiving home health aide services (Patient #2 & #3). The agency reported a current census of 61 patients at the time of the survey, including 41 who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: The agency policy, titled Home Health Aide Plan of Care, dated 1/2018, identified Home health aides are assigned to specific clients by a registered nurse or other appropriate skilled professional, with written client care instructions for a home health aide prepared by the registered nurse or other appropriate skilled professional. 1. Patient #2 had a start of care date of 6/4/21. The Plan of Care (POC), dated 8/6/21 to 10/4/21 to 10/5/21 to 12/3/21, included physician orders for skilled nursing and home health aide services. The home health aide care plan, dated 8/6/21 and 10/1/21, included registered nurse (RN) instructions to the aide to complete the following assigned tasks for the patient: change bed linens as needed, assist client with oxygen tubing, sanitize bathroom after client takes a shower, assist client to undress/dress, wash laundry and dry, assist with folding 1 times a week, meal prep for days in between nursing and aide visits, assist client to trim finger and toe nails, assist client to take a shower, apply lotion to arms, legs, back as client requests. Home Health Aide visit notes, dated 8/13, 8/18, 8/20, 8/25/21, 9/3, 9/7, 9/10, 9/14, 9/17, 9/24, 9/28/21, 10/1, 10/6 and 10/13/21, included documentation Staff failed to document completion of the tasks meal prep, assist client to trim finger and toe nails. Staff failed to always follow the aide written care plan as written. 2. Patient #3 had a start of care date of 10/16/20. The plan of care dated 8/12/21 to 10/10/21, included physician orders for skilled nursing services and home health aide services. The home health aide care plan, dated 8/20/21, included RN instructions to the aide to complete the following tasks: shampoo hair per clients request, help to dress/undress, lower extremity braces, AFP right hand/wrist, assist with showering. shaving and ted hose. The note also indicated the patient had a rash to the forearms bilaterally and right side of hip area and applying cortisone cream to the areas. The skilled nurse visit note, dated 6/30/21, included a supervision note of the home health aide which included observation of home health aide shaving and applying ted hose for the patient. The note also indicated the patient had a rash to the forearms bilaterally and right side of hip area and applying cortisone cream to the areas. Home health aide visit notes, dated 6/14/21 through 10/6/21, failed to identify the tasks of shaving, applying ted hose, AFO (ankle, foot orthosis) braces and applying cortisone cream. During an interview with agency staff on 10/19/21 at 3:45 PM, Staff D, HHA stated she assisted the patient with applying cortisone and antibiotic ointment, AFO (braces) and ted hose. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 5/24/21 through 5/26/21 . The survey found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: During agency staff entrance interviews with the Administrator and the Clinical Manager on 5/24/2021 at 9:10 AM, the Clinical Manager reported she is the person responsible for assigning admission visits to the agency registered nurses and tracking to monitor timeliness of completion of the initial visits. During agency staff interview on 5/25/2021 at 9:05 AM, the Clinical Manager reported if the agency receives a referral for home health care and cannot make the initial visit within 48 hours, agency staff notify the physician of the inability to meet the regulation and obtain an order to make the initial visit on a different date. If the physician specifically ordered a start of care date and the visit cannot be made as ordered, agency staff notify the physician of the inability to follow the order and obtain a new order for initiation of services. 1. Patient #3 had a start of care date of 4/22/2021. Clinical record review revealed the following: a. The physician's initial referral order, dated 4/12/2021 and sent to the agency by facsimile on 4/14/2021, ordered home health services for wound care to treat cellulitis in the right lower leg. b. The home health referral form, dated 4/14/2021, included the patient's name, date of birth, address, phone number and financial payer information. The referral documented skilled nursing services were required for a diagnosis of wounds. The physician making the referral was identified on the form. The referral form included an added notation at the bottom of the form stating "Not admitted 4/22/21- originally no good phone number". c. The Plan of Care, dated 4/22/2021 to 6/20/21, documented the start of care date of 4/22/2021 and included all of the same information found on the referral form, including the patient's address and telephone number. d. The clinical record lacked documentation of any follow up with the referring physician to report the inability to reach the patient to set up the initial visit. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The patient was not admitted to service until 8 days after receiving the referral. Agency staff interview revealed the following: e. On 5/26/2021 at 11:30 AM, the Clinical Manager reported the original telephone number received by the referral source was not correct. "I know I called the doctor and got approval to see the patient on 4/22/21 but didn't document it." The original referral form did not contain any other telephone contact for the patient other than the patient's current telephone number which matched the telephone number on the current home health Plan of Care. 2. Patient #8 had a start of care date of 4/26/2021 and was discharged from agency services on 5/8/2021. Clinical record review revealed the following: a. The home health referral form, dated 4/20/2021, included the patient's name, date of birth, address, phone number and financial payer information. The referral documented skilled nursing, home health aide and physical therapy services were required for diagnoses of kidney failure, paroxysmal atrial fibrillation, pneumonia and cystitis. The physician making the referral was identified on the form. The referral form was updated to reflect the patient's discharge from the inpatient acute care hospital on 4/23/2021 and the form was signed by the person taking the referral on 4/23/2021. b. The Plan of Care, dated 4/26/2021 to 6/24/21, documented the start of care date of 4/26/2021 and included all of the same information found on the referral form. c. The clinical record lacked documentation of any follow up with the referring physician to report the inability to see the patient within the 48 hour timeframe. The clinical record lacked documentation of any physician's order to delay the home health initiation of services. The patient was not admitted to service until 3 days after receiving notification of the patient's discharge from the inpatient facility. The above stated findings for Patients #3 and #8 were reviewed with the Administrator, Clinical Manager and multiple other agency nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: During agency staff interview on 5/25/2021 at 9:05 AM, the Clinical Manager reported the registered nurses perform a drug regimen review at start of care, recertification, resumption of care following hospitalization, with significant changes in patient condition and upon discharge from home health services by reviewing all medications taken by the patient, notifying the patient's physician of any concerns identified during the review. 1. Patient #1 had a start of care date of 12/27/2013. Clinical record review, home visit observation and relevant patient and agency staff interview revealed the following: a. On 5/24/2021 at 3:00 PM, the surveyor accompanied Staff C, Registered Nurse (RN) to Patient #1's residence. During the home visit, Staff C, RN, performed a recertification comprehensive assessment. As part of that assessment, the RN reviewed all of the medications taken by the patient. During the RN's review of the medications, the surveyor observed the following medication discrepancies: b. The home health medication list and Plan of Care, dated 3/27/2021 to 5/25/21, documented the patient took Lipitor 40 milligrams (mg) one tablet daily at bedtime. The prescription bottle in the patient's home, dated as filled by the pharmacy on 3/5/2021, included 80 mg tablets and directed the patient to take one 80 mg tablet at bedtime. The patient had medication planners set up for two weeks (set up by agency staff during the 5/21/2021 home visit). The surveyor observed one 80 mg tablet of Lipitor in each bedtime slot as ordered by the physician. The clinical record included documentation of an update to the comprehensive assessment at the time of recertification with accompanying drug regimen review, dated 3/25/2021, and documentation of an update to the comprehensive assessment at the time of resumption of care following hospitalization with accompanying drug regimen review, dated 5/7/2021. The RN documented performance of the drug regimen review with both comprehensive assessments; however, failed to identify the discrepancy in dosage from the previous dose of Lipitor 40 mg at bedtime to the change on 3/5/2021 to Lipitor 80 mg at bedtime. The agency medication list lacked inclusion of the new dose of medication taken by the patient. The Plan of Care, dated 3/25/2021 to 5/25/2021, documented an incorrect dose of the medication. c. The home health medication list and Plan of Care, dated 3/27/2021 to 5/25/21, documented the patient took Metoprolol ER 100 mg (2- 50 mg tablets) daily. The resumption of care physician orders, dated 5/4/2021 and sent to the agency by facsimile on 5/5/2021, included physician orders for a changed dose of Metoprolol to 75 mg (1.5- 50 mg tablets) daily. The clinical record included documentation of an update to the comprehensive assessment at the time of resumption of care following hospitalization with accompanying drug regimen review, dated 5/7/2021. The agency medication list lacked inclusion of the new dose of medication taken by the patient at the time of resumption of care. d. The surveyor observed Symbicort 160 micrograms (mcg)/4.5 mcg rescue inhaler in the patient's home. Patient interview during the home visit revealed the patient took Symbicort 2 actuations (puffs) twice daily and had been using the medication for several months. The physician office visit documentation, dated 2/2/21 and sent to the agency by facsimile on 2/18/2021, included Symbicort 160 mcg/4.5 mcg 2 puffs twice daily as taken by the the patient. The clinical record included documentation of an update to the comprehensive assessment at the time of recertification with accompanying drug regimen review, dated 3/25/2021, and documentation of an update to the comprehensive assessment at the time of resumption of care following hospitalization with accompanying drug regimen review, dated 5/7/2021. The RN documented performance of the drug regimen review with both comprehensive assessments; however, failed to identify the patient's use of Symbicort rescue inhaler. The agency medication list lacked inclusion of the new medication. The Plan of Care, dated 3/25/2021 to 5/25/2021, lacked inclusion of the medication. 2. Patient #2 had a start of care date of 9/21/2020. Clinical record review, home visit observation and relevant patient and agency staff interview revealed the following: a. On 5/26/2021 at 9:15 AM, the surveyor accompanied Staff F, RN to Patient #2's residence. During the home visit, Staff F, RN, performed a medication set up. During the RN's medication preparation, the surveyor observed the following medication discrepancies: b. The home health medication list and Plans of Care, dated 3/20/2021 to 5/18/21, documented the patient took Bentyl 10 mg three times daily as needed, and the Plan of Care, dated 5/19/2021 to 7/17/2021, documented the patient took Bentyl 10 mg once daily. The prescription bottles in the patient's home, dated as filled by the pharmacy on 1/14/2021 and 5/18/2021, included 10 mg tablets and directed the patient to take one 10 mg tablet 4 times each day. The clinical record included documentation of updates to the comprehensive assessment at the time of recertification with accompanying drug regimen reviews, dated 3/16/2021 and 5/18/2021. The RN documented performance of the drug regimen review with both comprehensive assessments; however, failed to identify the discrepancy between the frequency of administration on the prescription bottles and the frequency of administration identified on the Plans of care and medication list. c. The home health medication list and Plans of Care, dated 3/20/2021 to 5/18/21 and 5/19/2021 to 7/17/2021, documented the patient took DSS with Senna 50 mg/8.6 mg as needed for constipation. The surveyor observed a bottle of DSS 100 mg tablets in the home. Patient interview during the home visit revealed the patient used the DSS (stool softener) as needed two tablets twice daily. The clinical record included documentation of updates to the comprehensive assessment at the time of recertification with accompanying drug regimen reviews, dated 3/16/2021 and 5/18/2021. The RN documented performance of the drug regimen review with both comprehensive assessments; however, failed to identify the patient did not have DSS with Senna in the home but had DSS without any medications added. The above stated findings for Patients #1 and #2 were reviewed with the Administrator, Clinical Manager and multiple other agency nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: During agency staff interview on 5/25/2021 at 9:05 AM, the Clinical Manager reported registered nurses complete all comprehensive assessments for agency patients per agency policy. 1. Patient #6 had a start of care date of 4/23/2021 and was discharged to hospice care on 5/13/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/23/2021 to 6/21/2021, documented the patient's diagnosis of prostate cancer with bone metastasis. The Plan included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The initial comprehensive assessment, dated 4/23/2021, was electronically signed by Staff G, Registered Nurse (RN). c. Skilled nurse notes, dated 4/28/2021, 5/5/2021 and 5/12/2021, were electronically signed by Staff C, RN. d. The clinical record included documentation of visits made by the physical therapist and the occupational therapist. e. The update to the comprehensive assessment at the time of discharge, dated 5/13/2021, was documented and electronically signed by the Clinical Manager. The discharge assessment lacked documentation of any physical assessment findings. The discharge assessment did included OASIS data item coding. No documentation in the clinical record indicated the Clinical Manager had ever seen the patient directly to assess. During agency staff interview on 5/26/2021 at 11:55 AM, the Clinical Manager reported hospice needed to admit the patient to services, requiring the home health agency to discharge the patient. The Clinical Manager identified Staff C, RN, as the patient's case manager and reported Staff C, RN, was unavailable to complete the discharge assessment so the Clinical Manager completed the assessment via "telephone visit" to allow the hospice to admit the patient. The Clinical Manager confirmed she had not previously assessed the patient directly. The agency policy allowed for registered nurses only to complete the comprehensive assessments. Two RNs directly assessed Patient # 6. The Clinical Manager had never previously assessed the patient and did not make a home visit to directly assess the patient at the time of discharge. 2. Patient #7 had a start of care date of 4/6/2021 and was discharged to self care on 4/19/2021 with goals met. Clinical record review revealed the following: a. The Plan of Care, dated 4/6/2021 to 6/5/2021, documented the patient's diagnoses of osteoarthritis of the knee with total left knee joint replacement. The Plan included physician orders for physical therapy only. b. The patient was discharged from agency services on 4/19/2021. The update to the comprehensive assessment at the time of discharge was initiated on 4/19/2021 but no completed until 4/23/2021, 4 days after the patient's discharge. The above stated findings for Patients #6 and #7 were reviewed with the Administrator, Clinical Manager and multiple other agency nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: 1. Patient #1 had a start of care date of 12/27/2013. Clinical record review and home visit observation revealed the following: a. The Plans of Care, dated 1/26/2021 to 3/26/2021 and 3/27/2021 to 5/25/2021, documented the patient took Folic Acid 1 tablet daily. The Plan lacked documentation of the dose of Folic Acid in each tablet. The Progress Notes from a physician office visit, dated 2/2/2021 and sent to the agency by facsimile on 2/18/2021, included physician orders for Folic Acid 1 milligram (1000 mcg) daily. The hospital discharge orders, sent to the agency by facsimile on 5/5/2021, included physician orders for Folic Acid 1 milligram (1000 mcg) daily. On 5/24/2021 at 3:00 PM, the surveyor accompanied Staff C, Registered Nurse (RN) to Patient #1's residence. During the home visit, Staff C, RN, performed a recertification comprehensive assessment. As part of that assessment, the RN reviewed all of the medications taken by the patient. During the RN's review of the medications, the surveyor observed the bottle of Folic Acid in the home contained 1000 microgram (mcg) of Folic acid in each tablet. The Plans of Care did not include a complete medication order for Folic Acid, omitting the actual dose of medication taken by the patient despite the agency having knowledge of the dose of medication. b. The same Plans of Care included physician orders for home health aide visits twice weekly; however, lacked any tasks for the home health aide to perform. The home health aide assignments, dated 1/22/2021 and 3/25/2021, directed the home health aide to shower the patient, apply lotion and assist with dressing/undressing. 2. Patient #2 had a start of care date of 9/21/2020. Clinical record review, home visit observation and relevant patient and agency staff interview revealed the following: The Plans of Care, dated 11/20/2020 to 1/18/2021, 1/19/2021 to 3/19/2021, 3/20/2021 to 5/18/2021 and 5/19/2021 to 7/17/2021, included the following incomplete medication orders. a. "Nitroglycerin 0.4 mg sublingually (under the tongue) as needed"- The order was missing the frequency of administration of the medication, including parameters for administration and identification of he maximum number of times each day the patient could take on an as needed basis. b. "Pennsaid topical gel 1% four times daily as needed"- The order was missing identification of where the gel should be applied and the physician approved reason for as needed use of the medication. c. "Flonase 50 mcg/actuation once daily". d. "Zofran 4 mg as needed every 4 hours". The order was missing the physician approved reason for administration of the medication on an as needed basis. On 5/26/2021 at 9:15 AM, the surveyor accompanied Staff F, RN, to the patient's home. During the home visit, Staff F, RN, reported the patient applied the Pennsaid topical gel to both hands for relief of arthritic pain. During the home visit, the patient reported using the Flonase one actuation twice daily, once in the morning and once in the evening and took the Zofran for relief of nausea. Clinical record review revealed the following: e. The skilled nurse visit notes, dated 3/12, 3/24, 3/30, 4/5, 4/12, 4/28, 5/5 and 5/11/2021, documented the patient's use of ice packs and/or heating pad for relief of back pain. The Plans of Care, dated 3/20/2021 to 5/18/2021 and 5/19/2021 to 7/17/2021, lacked identification of the ice packs and heating pad as used to meet the patient's needs. During the home visit, patient interview revealed Patient #2 did use ice packs and heating pad for lower back pain relief. f. During the same home visit, Patient #2 reported using a scale to weigh each morning, portable blood pressure machine to monitor blood pressure each morning and a pulse oxygen monitor to obtain blood oxygen levels each morning for the past 5 years. The Plans of Care, dated 3/20/2021 to 5/18/2021 and 5/19/2021 to 7/17/2021, documented the patient's diagnoses as hypertension with heart failure, atrial fibrillation and chronic obstructive pulmonary disease (COPD). The Plans lacked identification of the scale, blood pressure machine or pulse oxygen monitor as equipment used by the patient to meet his/her needs. g. The same Plans of Care included physician orders for home health aide visits twice weekly; however, lacked any tasks for the home health aide to perform. The home health aide assignments, dated 2/21/2021 and 3/24/2021, directed the home health aide to shower the patient, brush the patient's hair, apply lotion and assist with dressing/undressing. 3. Patient #3 had a start of care date of 4/22/2021. Clinical record review revealed the following: The initial comprehensive assessment completed at the time of admission to home health services, dated 4/22/2021, documented the patient's use of tumeric root added to apple cider vinegar and cayenne pepper for relief of pain. The Plan of Care, dated 4/22/2021 to 6/20/21, lacked inclusion of the tumeric/applecider vinegar/cayenne pepper used by the patient for pain relief. 4. Patient #5 had a start of care date of 10/13/2020. Clinical record review revealed the following: a. The Plan of Care, dated 10/13/2020 to 12/11/2020, 12/12/2020 to 2/9/2021, 2/10/2021 to 4/10/2021 and 4/11/2021 to 6/9/2021, included the medication "Acetaminophen 500 mg every 4-6 hours as needed". The order was missing the physician approved reason for as needed use of the medication. b. The same Plans of Care included physician orders for home health aide visits twice weekly without skilled services; however, lacked any tasks for the home health aide to perform. The home health aide assignments, dated 2/8/2021 and 4/6/2021, directed the home health aide to shower the patient, brush the patient's hair, apply lotion and assist with dressing/undressing. 5. Patient #6 had a start of care date of 4/23/2021 and was discharged from agency services on 5/13/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/23/2021 to 6/21/2021, included physician orders for skilled nursing services and physical therapy/occupational therapy evaluation. The physician's interim order, dated 5/3/2021, added home health aide services to the patient's Plan once weekly for 1 week and twice weekly for 2 more weeks. The order lacked any planned interventions for the home health aide. The home health aide assignment, dated 4/28/2021, directed the aide to shower the patient, apply lotion as requested, apply compression stockings as an extension of nursing services, shave the patient as requested as an extension of nursing services and assist with dressing and undressing. The Plan of Care, dated 4/23/2021 to 6/21/2021, included the following incomplete medication orders: b. "Acetaminophen 650 mg every 4-6 hours as needed."- The order was missing the physician approved reason for as needed use of the medication 6. Patient #8 had a start of care date of 4/26/2021 and was discharged from agency services on 5/8/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/26/2021 to 6/24/2021, included physician orders for skilled nursing services, home health aide services and physical therapy/occupational therapy evaluation. The Plan directed home health aide services twice weekly for 2 weeks. The Plan lacked any planned interventions for the home health aide to perform. The home health aide assignment, dated 4/26/2021, directed the aide to shower the patient, apply lotion as requested, apply compression stockings if patient allows as an extension of nursing services and assist with dressing and undressing. The above stated findings were reviewed with the Administrator, Clinical Manager and multiple other registered nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: During agency staff entrance interviews on 5/24/2021 at 9:10 AM, the Clinical Manager reported each Plan of Care is updated with all interim and verbal orders. The order is signed by the physician and stored in the clinical record. The orders are then transcribed onto a working Plan of Care and the information is added to a duplicate of the current plan with the changes signified by *** prior to the new information. Each verbal or interim order will have an updated Plan of Care that is stored electronically, resulting in multiple copies of the same plan stored electronically but only the original is signed by the physician. 1. Patient #1 had a start of care date of 12/27/2013. Clinical record review revealed the following: a. The Plan of Care, dated 3/27/2021 to 5/25/2021, included physician orders for skilled nursing and home health aide. b. The resumption of care orders, dated 5/4/2021 and sent to the agency by facsimile on 5/5/2021, ordered a physical therapy and occupational therapy evaluation, c. The occupational therapist performed the evaluation visit on 5/13/2021. The occupational therapy evaluation, sent to the physician for signature, included a plan for occupational therapy visits 1-2 times weekly for 4 weeks to assist with provide safety education and work on activities of daily living to strengthen and increase activity tolerance. The evaluation also included multiple goals related to therapy care. d. The physical therapist performed the evaluation visit on 5/14/2021. The physical therapy evaluation, sent to the physician for signature, included a plan for physical therapy visits 1-2 times weekly for 4 weeks to assist with therapeutic exercise program. The evaluation also included multiple goals related to therapy care. The update to the Plan of Care, dated 5/14/2021, included the frequency and duration of planned physical and occupational therapy visits; however, lacked documentation of any planned treatments, modalities or goals for either therapy service. 2. Patient #6 had a start of care date of 4/23/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/23/2021 to 6/21/2021, included physician orders for physical therapy and occupational therapy evaluation, b. The occupational therapist performed the evaluation visit on 4/28/2021. The occupational therapy evaluation, sent to the physician for signature, included a plan for occupational therapy visits 1 time weekly for one week; then 2 times weekly for 2 more weeks to assist with provide safety education, edema management and work on activities of daily living to strengthen and increase activity tolerance. The evaluation also included multiple goals related to therapy care. c. The physical therapist performed the evaluation visit on 4/29/2021. The physical therapy evaluation, sent to the physician for signature, included a plan for physical therapy visits 1-2 times weekly for 3 weeks to assist with therapeutic exercise program and safety education. The evaluation also included multiple goals related to therapy care. The update to the Plan of Care, dated 4/29/2021, included the frequency and duration of planned physical and occupational therapy visits; however, lacked documentation of any planned treatments, modalities or goals for either therapy service. 3. Patient #7 had a start of care date of 4/7/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/7/2021 to 6/5/2021, included physician orders for physical therapy evaluation. b. The physical therapist performed the evaluation visit on 4/9/2021. The physical therapy evaluation, sent to the physician for signature, included a plan for physical therapy visits 1-2 times weekly for 2 weeks to assist with therapeutic exercise program, gait training, transfer training and safety education. The evaluation also included multiple goals related to therapy care. The update to the Plan of Care, dated 4/11/2021, included the frequency and duration of planned physical therapy visits; however, lacked documentation of any planned treatments, modalities or goals for the therapy service. 4. Patient #8 had a start of care date of 4/26/2021 and was discharged from agency services on 5/8/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/26/2021 to 6/24/2021, included physician orders for physical therapy and occupational therapy evaluation, b. The occupational therapist performed the evaluation visit on 4/27/2021. The occupational therapy evaluation, sent to the physician for signature, included a plan for occupational therapy visits 2 times weekly for 3 weeks to assist with provide safety education, upper body strengthening and work on activities of daily living to strengthen and increase activity tolerance. The evaluation also included multiple goals related to therapy care. c. The physical therapist performed the evaluation visit on 4/27/2021. The physical therapy evaluation, sent to the physician for signature, included a plan for physical therapy visits 1-2 times weekly for 2 weeks to assist with therapeutic exercise program, transfer and gait training, balance training and safety education related to climbing stairs. The evaluation also included multiple goals related to therapy care. The update to the Plan of Care, dated 4/27/2021, included the frequency and duration of planned physical and occupational therapy visits; however, lacked documentation of any planned treatments, modalities or goals for either therapy service. The above stated findings for Patients #1, #6, #7 and #8 were reviewed with the Administrator, Clinical Manager and multiple other registered nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: 1. Patient #6 had a start of care date of 4/23/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/23/2021 to 6/21/2021, included physician orders for skilled nursing services and physical therapy/occupational therapy evaluation. b. The physician's interim order, dated 5/3/2021, added home health aide services to the patient's Plan once weekly for 1 week and twice weekly for 2 more weeks. c. The home health aide assignment, dated 4/28/2021, directed the aide to shower the patient, apply lotion as requested, apply compression stockings as an extension of nursing services, shave the patient as requested as an extension of nursing services and assist with dressing and undressing. d. Shaving and application of compression stockings require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff I, Certified Nursing Assistant (CNA), provided care to Patient #6. e. Personnel file review revealed Staff I had never been competency tested to perform application of compression stockings or shaving patients. 2. Patient #8 had a start of care date of 4/26/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/26/2021 to 6/24/2021, included physician orders for skilled nursing services and home health aide services. c. The home health aide assignment, dated 4/26/2021, directed the aide to shower the patient, apply lotion as requested, apply compression stockings if patient allows as an extension of nursing services and assist with dressing and undressing. d. Application of compression stockings require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff J, CNA, provided care to Patient #8. e. Personnel file review revealed Staff J had never been competency tested to perform application of compression stockings. The above stated findings for Patients #6 and #8 were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: 1. Patient #6 had a start of care date of 4/23/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/23/2021 to 6/21/2021, included physician orders for skilled nursing services and physical therapy/occupational therapy evaluation. b. The physician's interim order, dated 5/3/2021, added home health aide services to the patient's Plan once weekly for 1 week and twice weekly for 2 more weeks. The order lacked any planned interventions for the home health aide. c. The home health aide assignment, dated 4/28/2021, directed the aide to shower the patient, apply lotion as requested, apply compression stockings as an extension of nursing services, shave the patient as requested as an extension of nursing services and assist with dressing and undressing. d. The home health aide visit notes, dated 4/30/2021 and 5/10/2021, did not document completion of applying Patient #6's compression stockings. The notes lacked documentation of the reason for omission of the task. e. The home health aide visit note, dated 5/7/2021, lacked documentation of any completed tasks. The note lacked documentation of the reason for omission of the task. 2. Patient #8 had a start of care date of 4/26/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/26/2021 to 6/24/2021, included physician orders for skilled nursing services and home health aide services. The Plan lacked any planned interventions for the home health aide. c. The home health aide assignment, dated 4/26/2021, directed the aide to shower the patient, apply lotion as requested, apply compression stockings if patient allows as an extension of nursing services and assist with dressing and undressing. d. The home health aide visit note, dated 4/30/2021, did not document completion of applying Patient #8's compression stockings. The note lacked documentation of the reason for omission of the task. The above stated findings for Patients #6 and #8 were reviewed with the Administrator, the Clinical Manager and multiple other registered nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Patient #5 had a start of care date of 10/13/2020. Clinical record review revealed the following: The Plans of Care, dated 10/13/2020 to 12/11/2020, 12/12/2020 to 2/9/2021, 2/10/2021 to 4/10/2021 and 4/11/2021 to 6/9/2021, included physician orders for home health aide services without the provision of skilled services. Patient #5's clinical record included only one supervisory note, dated 2/8/2021. The clinical record lacked any other documentation of home health aide supervision from admission through the end of the survey. During agency staff interview on 5/25/2021 at 1:51 PM, Staff G, Registered Nurse (RN) and primary case manager for Patient #5, reported she believed she had completed the supervisory visits every 60 days. The nurse reviewed the electronic clinical record with the surveyor and was unable to find documentation of any other visits except the 2/8/2021 supervisory visit. Immediately following the interview, the Administrator sat with the surveyor to review the electronic medical record and was also unable to find any other supervisory notes except the 2/8/2021 note. The above stated findings were reviewed with the Administrator, Clinical Manager and multiple other registered nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: 1. Patient #6 had a start of care date of 4/23/2021 and was discharged to a certified hospice on 5/13/2021. Clinical record review revealed the following: The discharge summary, completed on 5/13/2021, was sent to patient's physician on 5/14/2021. The discharge summary was never sent to the certified hospice provider, who would be caring for the patient after the home health agency's discharge. 2. Patient #7 had a start of care date of 4/7/2021 and was discharged to self care with goals met on 4/19/2021. Clinical record review revealed the following: The discharge summary, completed on 4/23/2021 (4 business days after the patient's discharge), was available in the electronic medical record; however, the agency was unable to provide documentation indicating the summary had been sent to the patient's physician. 3. Patient #8 had a start of care date of 4/26/202. Clinical record review revealed the following: a. The patient was hospitalized on 5/4/2021. The agency was notified of the transfer on 5/5/2021. b. The patient remained and was transferred to the hospital on Tuesday 5/4/2021 The patient remained in the hospital until Saturday 5/8/2021, at which time the patient was transferred to a long term care facility for permanent placement and did not return to home health services. c. The nurse completed the transfer summary on 5/13/2021, 6 business days after receiving knowledge of the transfer. There was no evidence in the clinical record indicating the summary was ever sent to the physician caring for the patient in either the hospital or the long term care facility. The above stated findings for Patients #6, #7 or #8 were reviewed with the Administrator, Clinical Manager and multiple other registered nurses and administrative staff. The agency provided no additional information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: During agency staff entrance interviews on 5/24/2021 at 9:10 AM, the Administrator and the Clinical Manager reported all patient documentation should be completed within 48 hours of the visit date for nurses and home health aides. Therapists complete the documentation for the entire week, delivering the documents to the home health agency by the end of the day on Fridays for the entire week. During agency staff interview on 5/24/2021 at 1:40 PM, the Administrator reported the home health aide and therapy notes for the current month are stored in folders at the reception area of the agency after delivery to the office until billing at the end of the month, then placed into patient clinical records. 1. Patient #1 had a start of care date of 12/27/2013. Clinical record review revealed the following: a. The update to comprehensive assessment at the time of resumption of care following hospitalization, dated 5/7/2021, stored in the patient's electronic medical record when reviewed on 5/24/2021 without being electronically signed. b. The patient was hospitalized from 4/28/2021 to 5/6/2021. The notes documenting telephone calls with the hospital staff caring for Patient #1, dated 4/29/2021 and 5/5/2021, had never been electronically signed by the author of the document. The documents were stored electronically. c. The skilled nursing notes, dated 1/11, 2/1, 2/19, 3/22, 4/6, 4/17 and 5/17/2021, included the electronic signature of Staff D, Licensed Practical Nurse (LPN), but failed to identify the credentials of the LPN in the electronic signature. d. The supervisory notes, dated 1/11, 2/3, 2/10, 3/19 and 4/17/2021, included the electronic signature of Staff D, LPN, but failed to identify the credentials of the LPN in the electronic signature. e. The physical therapy evaluation, dated 5/14/2021, were signed by the physical therapist; however, lacked a date and time of signature. f. On 5/24/2021 at 1:35 PM, the surveyor found no therapy notes in the record. g. The surveyor found the following documents in the folders in the reception area: Physical therapy evaluation, dated 5/14/2021; Occupational therapy evaluation, dated 5/13/2021; Progress notes written by physical therapy on 5/19/2021 and 5/21/2021; Occupational therapy visit notes, dated 5/18/2021 and 5/21/2021; Home Health Aide visit notes, dated 5/11/2021, 5/18/2021 and 5/21/2021. h. The home health aide visit notes, dated 3/18, 3/23, 3/26, 3/30, 4/2, 4/6, 4/9, 4/13, 4/16, 4/20, 4/23, 5/11, 5/15, 5/18 and 5/21/2021, were hand signed, dated and timed; however, the aide did not include credentials. 2. Patient #2 had a start of care date of 9/21/2020. Clinical record review revealed the following: a. The note documenting a telephone call from the patient to discuss issues with constipation, dated 5/20/2021, had never been electronically signed by the author of the document. The documents were stored electronically. b. The surveyor found no home health aide notes in the clinical record for the month of May 2021. The surveyor found the Home Health Aide visit notes, dated 5/4, 5/6, 5/10, 5/13, 5/18, 5/20/2021, in the folders stored in the reception area. c. The home health aide visit notes, dated 3/15, 3/17, 3/22, 3/25, 3/29, 4/1, 4/6, 4/8, 4/12, 4/15, 4/19, 4/22, 4/26, 4/29, 5/4, 5/6, 5/10, 5/13, 5/18 and 5/20/2021, were hand signed, dated and timed; however, the aide did not include credentials. 3. Patient #5 had a start of care date of 10/13/2020. Clinical record revealed the following: a. The surveyor found no home health aide visit notes in the clinical record for the month of May 2021. The surveyor found the Home Health Aide visit notes, dated 5/3, 5/6, 5/10, 5/13, 5/17 and 5/20/2021, in the folders stored in the reception area. b. The home health aide visit notes, dated 3/8, 3/11, 3/15, 3/18, 3/22, 3/25, 3/29, 4/1, 4/6, 4/8, 4/12, 4/15, 4/19, 4/22, 4/26, 4/29, 5/3, 5/6, 5/10, 5/13, 5/18 and 5/20/2021, were hand signed, dated and timed; however, the aide did not include credentials. 4. Patient #6 had a start of care date of 4/23/2021 and was discharged to a certified hospice provider on 5/13/2021. Clinical record review revealed the following: a. The physical therapy evaluation, dated 4/29/2021, and visit note, dated 5/4/2021, were signed by the physical therapist; however, lacked a date and time of signature. b. The surveyor found the following documents in the folders in the reception area: Occupational therapy evaluation, dated 5/13/2021; Physical therapy visit note, dated 5/4/2021, and a progress note, dated 4/26/2021; Occupational therapy visit notes, dated 5/3/2021, 5/6/2021, 5/11/2021, 5/18/2021 and a progress note, dated 5/14/2021; Home Health Aide visit notes, dated 5/4/2021, 5/7/2021 and 5/11/2021. The patient was discharged on 5/13/2021 yet the documents had never been incorporated into the clinical record. h. The home health aide visit notes, dated 4/30/2021; and 5/4,7,10/2021, were hand signed, dated and timed; however, the aide did not include credentials. 5. Patient #7 had a start of care date of 4/7/2021 and was discharged from agency services on 4/19/2021. Clinical record review revealed the following: a. The note documenting a telephone call between the nurse and the therapist discussing the patient, dated 4/9/2021, had never been electronically signed by the author of the document. The documents were stored electronically. b. The surveyor found the following documents in the folder in the reception area: Physical therapy evaluation, dated 4/8/2021; Physical therapy visit notes 4/12/2021 and 4/15/2021. The patient was discharged on 4/19/2021 and none of the therapy notes had been incorporated into the patient's clinical record. 6. Patient #8 had a start of care date of 4/26/2021 and was discharged from agency services on 5/8/2021. Clinical record review revealed the following: a. Two notes, both dated 4/27/2021, documenting telephone calls between the nurse and the therapist discussing the patient had never been electronically signed by the author of the document. The documents were stored electronically. b. The surveyor found the following documents in the folder in the reception area: Physical therapy evaluation, dated 4/27/2021; Occupational therapy evaluation, dated 4/27/2021; Physical therapy visit note 5/3/2021; Occupational therapy visit note, dated 5/4/2021 The patient was discharged on 5/8/2021 and none of the therapy notes had been incorporated into the patient's clinical record. The above stated findings were reviewed with the Administrator, Clinical Manager and multiple other registered nurses and administrative staff. The agency provided no additional information prior to the end of the survey.