Every finding on record at Covenant Medical Center Inc

The combined COVID-19 Focused Infection Control Survey and recertification survey conducted from 8/9/2021 to 8/16/2021, found the agency operating in substantial compliance with the COVID-19 requirements for emergency preparedness and pandemic illnesses. The recertification survey identified the following standard level deficient practices related to the Establishment of Emergency Preparedness requirements.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness policies and agency staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The agency reported a current census of 105 patients at the time of the survey. Failure to have procedures in place for to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: During an interview on 8/16/21 at 2:45 PM, the surveyor notified Staff D, RN Supervisor in charge of Emergency Preparedness, of an inability to find a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Staff D, RN Supervisor reported an inability to find the specific language in the policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The above findings were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and RN Supervisors. Agency staff 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 a recertification survey from 8/9/2021 through 8/16/2021 . The survey found the agency 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:

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: Based on agency policy review, clinical record review, home visit observation, patient interview and agency staff interviews, the agency failed to ensure a registered nurse (RN) completed a drug regimen review, reconciled the medications and contacted the physician, if necessary, in therapy only cases for 1 of 1 sampled patients receiving only therapy services (Patient #3). The agency reported a census of 105 patients at the time of the survey, including 11 who received therapy services with no skilled nursing. Failure to ensure a registered nurse reviewed patient medications at the time of each comprehensive assessment by using a current and accurate list of medications taken by the therapist in a therapy only case at the time of the assessment increased the potential for unidentified medication interactions, patient non-compliance, ineffective medication therapy and side effect risks to the patient. Findings include: According to the agency policy, titled Medication, Dispensing in the Home and updated 4/19/2021, on admission the admitting clinician verifies the medication list is correct and completes a drug regimen review within the electronic medical record. The physician will be contacted immediately if there is a need to obtain, clarify or verify physician's orders. The nurse is responsible for documenting in the patients' electronic medical record the date, time and physician response for any issues noted in the drug regimen review. The clinician must complete a physician order for ALL medications, both prescribed and over-the-counter including: the patients' name; drug name; strength and dosing form; route; times to take and directions for use; date and time ordered; and the ordering physician name. Prescriptions that are new or modified can be identified through the prescription label and do not require a verbal order. These medications may be noted in the electronic medical record. During agency staff interview on 8/9/2021 at 11:20 AM, the RN Clinical Manager reported the clinician completing the comprehensive assessment performs 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. The review is documented within the comprehensive assessment note. Clinicians are also directed to review the patients' medications at least weekly and with changes in medications and perform a drug regimen review to capture duplication, side effects, ineffective medications and any potential medication interactions. Patient #3 had a start of care date of 7/6/2021. Clinical record review, home visit observation and associated patient and agency staff interviews revealed the following: The Plan of Care, dated 7/7/2021 to 9/3/2021, included physician orders for physical therapy services twice weekly for 6 weeks. The Plan lacked identification of any other planned service. The patient's electronic medical record included a hospital discharge summary which included a list of medications, dated 6/30/2021 and sent to the agency by facsimile on 6/30/2021 and the home health agency's medication profile. On 8/11/2021 at 9:00 AM, the surveyor accompanied Staff H, Physical Therapist to Patient #3's residence. During the home visit, the surveyor and the Physical Therapist reviewed the medications in the patient's home. Staff H, Physical Therapist, verified she was the clinician who admitted Patient #3 to services and completed the initial comprehensive assessment at start of care with accompanying drug regimen review. During comparison of the three above stated documents and associated interviews with the patient and Staff H, Physical Therapist, the surveyor noted the following discrepancies: a. The hospital discharge summary included the medication Albuterol 90 micrograms (mcg)/actuation 1 puff inhalation every 6 hours as needed for wheezing. The Plan of Care included Albuterol 90 mcg/actuation 2 puff inhalations every 6 hours as needed for wheezing. The agency medication profile included Albuterol 90 mcg/actuation 2 puff inhalations every 6 hours as needed for wheezing. The medication entry included a start date of 7/7/2021. Patient interview during the home visit revealed Patient #3 reported only using 1 puff of the Albuterol inhalant as needed stating "that is what I was told to do- never done 2 puffs." The medication dosage was entered incorrectly on the patient's Plan of Care and agency medication profile. b. The hospital discharge summary included the medication cetirizine 10 milligrams (mg) every day. The Plan of Care lacked inclusion of cetirizine as a medication taken by the patient. The agency medication profile included cetirizine 10 mg every day, beginning on 7/19/2021. Patient interview during the home visit revealed Patient #3 had been taking cetirizine 10 mg daily since admission to the home health agency as prescribed by the physician. Staff H, Physical Therapist, reported he/she added the medication to the agency medication profile on 7/19/2021 after noting he/she had inadvertently not included the medication on the Plan of Care at start of care. c. The hospital discharge summary included the medication Calcium Carbonate 600 mg every day. During the home visit, the surveyor observed the prescription label identified Calcium citrate 250 mg. The Plan of Care included the medication Calcium Carbonate 250 mg/ 625 mg every day. The agency medication profile included Calcium Carbonate 250/ 625 mg every day. The clinical record lacked any documentation of reconciliation of the medication with the physician due to the discrepancy between the discharge order and what was in the home taken by the patient. The incorrect medication and dosage was added to the Plan of Care and the agency medication profile. d. The hospital discharge summary included oxygen 2 liters per nasal cannula. The Plan of Care lacked inclusion of oxygen as a medication taken by the patient. The agency medication profile included oxygen 2 liters to 3.5 liters continuous, beginning on 7/19/2021. Patient interview during the home visit revealed Patient #3 had been using oxygen with a dose range of 2-3 liters since admission to the home health agency as prescribed by the physician. The dose during the visit was 2.5 liters. Staff H, Physical Therapist, reported he/she added the medication to the agency medication profile on 7/19/2021 after noting he/she had inadvertently not included the medication on the Plan of Care at start of care. The clinical record lacked any documentation of reconciliation of the medication with the physician due to the discrepancy between the discharge order and dosage used in the home taken by the patient. The incorrect medication dosage was added to the Plan of Care and the agency medication profile. e. The hospital discharge summary included the medication topiramate 100 mg daily. The Plan of Care included topiramate 100 mg daily. The agency's medication profile included topiramate 100 mg twice daily beginning on 7/19/2021. During the home visit, the surveyor observed a prescription medication label, dated as initiated on 6/22/2021, directing the patient to take topiramate 100 mg twice daily. Patient interview during the home visit revealed Patient #3 had been taking topiramate 100 mg twice daily since admission to home health. Staff H, Physical Therapist, reported he/she added the medication to the agency medication profile on 7/19/2021 after noting he/she had inadvertently included the wrong frequency on the Plan of Care at start of care. The clinical record lacked any documentation of reconciliation of the medication with the physician due to the discrepancy between the discharge order and dosage used in the home taken by the patient. The clinical record lacked any documentation of review of the patient's medications by an RN, lacked any reconciliation or clarification with the physician as part of the regulatory requirements for the drug regimen review. The above stated findings were reviewed with the RN Clinical Manager, the RN Financial Manager and multiple RN Supervisors. The agency provided no additional information prior to the end of the survey.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments with accompanying drug regimen review between day 56 and 60 of each 60 day certification period for 2 of 6 sampled patients requiring an update to the comprehensive assessment at the time of recertification (Patients #7 and #8). The agency reported a census of 105 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Clinical Record and updated 3/2021, agency clinicians must complete documentation of OASIS data sets per CMS regulation. The update to the comprehensive assessment at the time of recertification will be included in the last five days of the current certification for all patients that have OASIS data collected. The assessment for OASIS exempt patients will be completed up to and including day 60 of each certification period. 1. Patient #8 had a start of care date of 12/7/2019 and received skilled nursing and home health aide services paid for by Medicaid, thereby requiring the collection of OASIS data set. Clinical record revealed the following: a. The Plans of Care, dated 1/30/2021 to 3/30/2021 and 3/31/2021 to 5/29/2021, included physician orders for skilled nursing and home health aide services. b. The patient's clinical record included an update to the comprehensive assessment at the time of recertification, dated 3/30/2021 (day 60 of the current certification period). The assessment was electronically signed as complete on 3/31/2021, the first day of the upcoming certification period, making the assessment one day late. 2. Patient #7 had a start of care date of 1/1/2021. Clinical record revealed the following: a. The Plans of Care, dated 1/2/2021 to 3/2/2021 and 3/3/2021 to 5/1/2021, included physician orders for skilled nursing services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 2/26/2021 (day 56 of the certification period) was not completed until 3/3/2021, 1 day into the new certification period. The certification period ended on 3/2/2021. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. The above findings were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff provided no additional information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 2 of 2 sampled patients requiring a resumption of care assessment (Patient #6 and #7). The agency provided services to 105 patients at the time of the survey and performed 16 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Transfer/Resumption of Care, dated 8/2018, upon discharge from an inpatient facility, an OASIS assessment/visit occurs within 48 hours. In the event the agency is not notified of the inpatient discharge, the OASIS assessment/visit will be completed when the inpatient discharge is discovered. The visit may be delayed when the physician specifies the date of the first visit. 1. Patient #6 had a start of care date of 4/23/2021 and a discharge date of 6/30/2021. Clinical record review revealed the following: a. The transfer assessment, dated 5/19/2021, documented the patient was hospitalized due to a stroke. b. The update to the comprehensive assessment at the time of resumption of care, dated 6/14/2021, documented the patient was discharged from the hospital on 6/12/2021. The nurse initiated the update to the assessment on 6/14/2021 but did not complete the assessment until 6/16/2021, 4 days after the patient's return home from the inpatient stay. The assessment was completed 4 days late as required by regulation and the agency's own policy. 2. Patient #7 had a start of care date of 1/2/2021. Clinical record review revealed the following: a. The skilled nursing visit note, dated 7/2/2021, documented the home health nurse called for an ambulance and the patient was taken to the emergency room. b. The communication note, dated 7/4/2021, documented the agency called the hospital and was informed the patient remained inpatient on observation status. c. A faxed received from the agency, dated 7/6/2021, documented the patient was admitted to the hospital on 7/2/2021 and discharged from the hospital on 7/5/2021. d. The transfer assessment, dated 7/6/21, documented the patient was hospitalized for a respiratory infection. e. The communication note, dated 7/6/21, completed by the clinical manager revealed the visit note was unlocked on 7/7/21 after finding out the hospital stay was an inpatient stay and the visit would need to be a resumption of care visit, not routine visit. f. The update to the comprehensive assessment at the time of resumption of care, dated 7/6/2021, documented the patient was discharged from the hospital on 7/5/2021. The nurse initiated the update to the assessment on 7/6/2021 but did not complete the assessment until 7/9/2021, 3 days after the agency's knowledge of the patient's return home from the inpatient stay. The assessment was completed 1 day late as required by regulation and the agency's own policy. The above findings were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff 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: Based on agency policy and clinical record review, the agency failed to ensure completion of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 1 of 3 sampled patients requiring a discharge comprehensive assessment (Patient #12). The agency reported a census of 105 patients at the time of the survey and discharged 285 patients between 1/1/2021 and 7/31/2021. Failure to accurately and thoroughly complete discharge comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Clinical Record and updated 3/2021, agency clinicians must complete documentation of OASIS data sets per CMS regulation. Patient #12, an infant, had a start of care date of 8/5/2020 and was discharged from agency services on 7/28/2021. Clinical record revealed the following: a. The Plan of Care, dated 6/1/2021 to 7/30/2021, included physician orders for skilled nursing services once monthly for 2 months. b. The routine skilled nursing visit note, dated 6/29/2021, documented a plan for the patient to visit the physician prior to the end of the certification period to determine if continued services were necessary. c. The Discharge Instructions/Notification, dated 7/28/2021, documented the patient met all goals and could be discharged from home health services. The Instructions were marked as reviewed with the patient's guardian by phone or mailed out. d. The patient's clinical record lacked documentation of an update to the comprehensive assessment at the time of discharge. The above stated findings were reviewed with the RN Clinical Manager and the RN Financial Manager. 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: Based on clinical record review, agency policy review, home visit observation, agency staff interview and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate medication/treatment orders for 7 of 11 sampled patients (Patients #1, #2, #3, #7, #8, #9 and #12). The agency reported a current census of 105 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Provider Orders/Plan of Care, dated 5/2021 the plan of care will include the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, the types of services, supplies and equipment required, the frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, all medications and treatments, safety measures to protect against injury, a description of the patient's risk for emergency hospitalization and hospital readmission, an all necessary interventions to address the underlying risk factors, patient-specific interventions and education, measurable outcomes and goals, patient and caregiver education and training to facilitate discharge, information related to advance directives, and disciplines involved in providing care. During agency staff interview on 8/9/2021 at 11:20 AM, the RN Clinical Manager reported clinicians are directed to review the patients' medications at least weekly and with changes in medications and perform a drug regimen review to capture duplication, side effects, ineffective medications and any potential medication interactions. 1. Patient #2 had a start of care date of 4/14/2021. Clinical record review revealed: a. The Plans of Care, dated 2/20/21 to 4/20/21, 4/21/21 to 6/19, and 6/20/21 to 8/18/21, included physician orders for skilled nursing visits two times per month for medication set up and assessment and included orders for Bevespi Aerosphere inhaler 9 micrograms (mcg)-4.8 mcg with instructions to inhale 2 puffs 2 times per day. During a home visit observation on 8/10/21 at 9:32 AM, with Staff G, Registered Nurse (RN), the surveyor reviewed with the patient and nurse current medications in use. Interview with the patient revealed the patient kept the Bevespi inhaler in a purse at all times and the inhaler was "hardly ever used" and when patient does use it, it is mostly at night. The patient was unsure when the last time Bevespi inhaler was used. b. The Plans of Care failed to accurately identify the correct dosage and frequency of the Bevespi used to meet the patient's needs. c. The Plans of Care, dated 2/20/21 to 4/20/21, 4/21/21 to 6/19, and 6/20/21 to 8/18/21, identified the following equipment and supplies as equipment used to meet the patient's needs: single point cane, wheeled walker, hand held shower, shower chair, medication boxes, blood pressure monitor, life line and scale. During the same home visit observation on 8/10/21 at 9:32 AM, with Staff G, Registered Nurse (RN), the surveyor observed grab bars in the patient's bathroom located by the toilet and the shower. Interview with the patient revealed the grab bars have been there since the patient moved into the apartment and has lived in the apartment for "quite awhile" due to concerns of navigating stairs in previous home. d. The Plans of Care failed to identify the grab bars as equipment used to meet the patient's needs. The agency failed to include all the required elements of the individualized plan of care per regulation. 2. Patient #7 had a start of care date of 1/21/2021. Clinical record review revealed: a. The Plans of Care, dated 5/2/21 to 6/30/21 and 7/1/21 to 8/29/21, identified the following equipment and supplies used to meet the patient's needs: single point cane, standard walker, wheeled walker, chair lift, gait belt, shower chair, sharps, and medication box b. Skilled nursing visit note, dated 6/7/21, documented the nurse assisted the patient in the bathroom and helped change the patient's depends. c. The Plans of Care failed to identify the depends as equipment used to meet the patient's needs. d. The skilled nursing visit notes, dated 6/14/21 and 6/21/21, documented the patient's use of gel cushion used for pressure relief for treatment of the patient's pressure ulcer. e. The Plans of Care failed to identify the gel cushion as equipment used to meet the patient's needs. The agency failed to include all the required elements of the individualized plan of care per regulation. 3. Patient #1 had a start of care date of 6/13/2021. Clinical record review, home visit observation and associated patient caregiver and agency staff interviews revealed the following: a. The Plan of Care, dated 6/13/2021 to 8/11/2021, included physician orders skilled nursing visits once weekly. The Plan directed the nurse to assess patient medications during each visit and instruct as necessary. The Plan included a physician order for metoprolol 100 milligrams (mg) one tablet daily. The order was dated as initiated on 6/13/2021. b. On 8/10/2021 at 8:15 AM, the surveyor accompanied Staff I, RN, to Patient #1's home. The patient's adult child was present during the home visit. The adult child was responsible for setting up the patient's medications in a weekly planner. During the home visit, Staff I, RN, reviewed the patient's medications. The prescription bottle of metoprolol contained 25 mg tablets. The label, dated 7/14/2021, directed the patient to take one 25 mg tablet every day. During patient caregiver interview on 8/10/2021 during the home visit, the adult child of Patient #1 reported the patient was seen by the cardiologist on 7/13/2021 and the medication was changed at that time. The adult child reported giving the patient one tablet daily from the prescription bottle described above. Staff I, RN, contacted the cardiologist office, pharmacy and adult child to reconcile the medication change. The physician had decreased the dose of metoprolol on 7/13/2021. The pharmacy reported filling the prescription on 7/14/2021 and the adult child of Patient #1 picked up the new prescription on 7/22/2021. The adult child reported taking the new bottle to the patient's home on 7/26/2021 and filled the medication planner with the new dose. The skilled nurse visit note, dated 8/6/2021, documented the nurse reviewed the patient's medications, finding no changes, despite the new dose of metoprolol. The discrepancy was not identified until 8/10/21 during the co-visit with the surveyor. c. The initial comprehensive assessment completed at the time of start of care, dated 6/13/2021, documented the patient used the following equipment to meet his/her needs: oxygen, CPAP (Continuous Positive Airway Pressure- used for sleep apnea to deliver oxygen), cane, walker when outside, nebulizer (used to administer a liquid medication as an inhaled mist), hospital bed, lifeline (emergency response system), pill box, shower chair, hand held shower, grab bars and a reacher (a stick with a claw at the end to pick items up that are out of reach.) The Plan of Care, dated 6/13/2021 to 8/11/2021, included a list of equipment and supplies used by the patient to meet his/her needs; however, the list did not include grab bars, a hand held shower, shower chair or a reacher. During the home visit on 8/10/2021 at 8:15 AM, the surveyor observed the patient had grab bars in the bathroom, a hand held shower, a shower chair and a reacher. The Plan of Care failed to identify all equipment and supplies used to meet the patient's needs. 4. Patient #3 had a start of care date of 7/6/2021. The Plan of Care, dated 7/6/2021 to 9/3/2021, documented the patient's diagnoses systemic lupus, acute exacerbation of asthma, acute respiratory failure with hypoxia and personal history of Covid 19. Clinical record review and associated patient and agency staff interviews revealed the following: On 8/11/2021 at 9:00 AM, the surveyor accompanied Staff H, Physical Therapist, to Patient #3's home. During the home visit, Staff H, Physical Therapist, requested the patient obtain the pulse oximeter (a portable device placed on the patient's finger to measure the level of oxygen in the blood.) The surveyor observed the patient remove the pulse oximeter from the table drawer next to the patient's chair. The surveyor observed the patient use the pulse oximeter independently multiple times during the visit while performing therapy exercises. Patient interview during the home visit revealed the patient used the pulse oximeter multiple throughout each day to determine the need for rest or the need to increase or decrease oxygen dosage. During agency staff interview while in the home, Staff H, Physical Therapist, reported she was aware of the patient's use of the pulse oximeter. The Plan of Care, dated 7/6/2021 to 9/3/2021, lacked inclusion of the pulse oximeter as equipment used to meet the patient's needs. 5. Patient #8 had a start of care date of 12/7/2019. Clinical record review revealed the following: The Plan of Care, dated 5/30/2021 to 7/28/2021, included a physician order for Milk Thistle (over-the-counter medication) three 500 mg capsules once daily. The skilled nurse visit note, dated 7/21/2021, documented Patient #8 reported no longer using the Milk Thistle on a routine basis, switching to taking the medication only on an as needed basis. The agency recertified the patient for an additional 60 days of care. The new Plan of Care, dated 7/29/2021 to 9/26/2021, continued to include the Milk Thistle scheduled three 500 mg capsules once daily despite the patient's report of only as needed use. 6. Patient #9 had a start of care date of 5/13/2021. Clinical record review revealed the following: The initial comprehensive assessment completed at the time of start of care, dated 5/13/2021, documented the patient used the following equipment to meet his/her needs: wheeled walker, catheter and supplies, lift chair, raised toilet seat, grab bars, hand held shower, tub bench, life line (emergency response system) and pill box. The occupational therapy evaluation, dated 5/17/2021, documented the patient also used a bedside commode, long handled shoe horn, gait belt and a wheel chair. The Plan of Care, dated 5/13/2021 to 7/11/2021, included a list of equipment and supplies used by the patient to meet his/her needs; however, the list did not include gait belt, wheel chair, long handled shoe horn, bedside commode, grab bars, a hand held shower, tub bench, lifeline or raised toilet seat. 7. Patient #12, an infant, had a start of care date of 8/5/2020 and was discharged from home health services on 7/28/2021. Clinical record review revealed: a. The skilled nurse visit note, dated 1/28/2021, documented the infant experienced lactose intolerance and was started on Similac Total Comfort formula. The Plan of Care, dated 2/1/2021 to 4/1/2021, did not identify the type of formula used by the infant. b. The Plan of Care, dated 4/2/2021 to 5/31/2021, documented the infant received Similac Pro Advanced formula. The skilled nurse notes, dated 4/27/2021 and 5/27/2021, documented the infant received Similac Total Comfort formula due to lactose intolerance. c. The Plan of Care, dated 6/1/2021 to 7/30/2021, documented the infant received Similac Total Comfort formula. The Plan also indicated the patient supplemented the diet with Pediasure and Enfagrow; however, the Plan failed to include the amount of each supplement or frequency of administration. The above stated findings were reviewed with the RN Clinical Manager, the RN Financial Manager and multiple RN supervisors. 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: Based on agency policy review and clinical record review, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 9 of 9 sampled patients with new verbal/interim orders. (Patients #1, #3, #6, #7, #8, #9, #10, #11 and #12) The agency reported a current census of 105 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to the agency policy, titled Provider Licensure Orders and updated 5/2021, the initial Plan of Care for each patient will be completed within 7 working days and then updated at least every 60 days. In the case of a resumption of care following inpatient stay or a significant change in patient condition, the Plan of Care will be updated and sent to the physician for signature. According to the agency policy, titled Medications, Dispensing in the Home and updated 4/2019, the clinical record must include a completed physician order for ALL medications, both prescription and over-the-counter. Prescriptions that are new or modified can be identified through the prescription label without obtaining a verbal order. These medications will be noted in the electronic clinical record. During agency staff interview on 8/10/2021 at 11:50 AM, the RN Financial Manager reported the agency's electronic medical record system has the ability to complete verbal/interim orders, send to the physician for signature and store signed copy in paper charts. At the time of resumption of care and significant change in condition of the patient, the system has the ability to complete a Plan of Care update, send to the physician for signature and store the signed copy in paper charts. The RN Financial Manager reported the system only allows orders to be done either in interim order format, signed by the physician, or in Plan of Care update, signed by the physician, but not both so the agency decided to only do interim orders in verbal order format and not added to a Plan of Care update unless at the time of resumption of care or significant changes have occurred. During agency staff interview on 8/10/2021 at 2:30 PM, the RN Financial Manager reported she spoke to representatives of the agency's electronic medical record system and the system does have a way to complete a verbal order, send for signature and then add the orders to a Plan of Care update that does not require physician signature. The agency will begin to use Plan of Care updates as required by regulation. 1. Patient #1 had a start of care date of 6/13/2021. Clinical record review revealed the following: a. The Plan of Care, dated 6/13/2021 to 8/11/2021, included orders for skilled nursing visits twice weekly for 1 week then once weekly for 4 weeks. The clinical record included a physician's order, dated 7/14/2021, ordering continued skilled nursing services once weekly for an additional 4 weeks and 3 as needed visits for medication changes. The verbal order was not added to a Plan of Care update. b. The Plan of Care, dated 6/13/2021 to 8/11/2021, included the following medication orders: Furosemide 120 milligrams every morning and 80 milligrams (mg) every evening; Gabapentin 600 mg at bedtime; Oxygen 3 liters continuously. The clinical record included the following physician interim orders: 6/30/2021- change oxygen to 3 liters continuously at night and as needed during the day for shortness of breath; 7/2/2021- discontinue Gabapentin; 7/2/2021- change oxygen to 3 liters at night with CPAP (Continuous positive airway pressure) and 3 liters during the day as needed for shortness of breath and to keep pulse oxygen levels at or greater than 90 percent; and 8/7/2021- Furosemide 120 mg twice daily through 8/14/2021 then 120 mg every morning and 80 mg every evening. None of the above stated verbal orders were added to a Plan of Care update. 2. Patient #3 had a start of care date of 7/6/2021. Clinical record review revealed the following: The physical therapy visit note, dated 7/19/2021, documented the therapist noted a prescription label ordering Vitamin D3 1250 mg 50,000 iu (international units) once weekly on Tuesdays. The therapist added the medication to the agency medication profile as allowed by agency policy when the prescription medication can be read on bottle label; however, the medication was never added to a Plan of Care update. 3. Patient #8 had a start of care date of 12/7/2019. Clinical record review revealed the following: The Plan of Care, dated 12/1/2020 to 1/29/2021, did not include orders for Motrin. The clinical record included a physician interim order, dated 12/22/2020, ordering Motrin 400 mg every 2 weeks the night before changing of the urinary catheter. The verbal order was not added to a Plan of Care update. 4. Patient #9 had a start of care date of 5/13/2021. Clinical record review revealed the following: The Plan of Care, dated 5/13/2021 to 7/11/2021, lacked identification of an EZ stand or hospital bed as equipment used to meet the patient's needs. The initial comprehensive assessment completed at start of care, dated 5/13/2021, documented the family was attempting to obtain both an EZ stand and hospital bed for the patient's use. The skilled nurse visit note, dated 5/28/2021, documented the patient was now using the EZ stand with transfers performed by the family and privately paid caregivers and a hospital bed. Neither the EZ stand or hospital bed were added to a Plan of Care update. 5. Patient #12, an infant, had a start of care date of 8/5/2020 and was discharged from home health services on 7/28/2021. Clinical record review revealed the following: The Plan of Care, dated 8/5/2021 to 10/3/2021, lacked identification of an owlet (a smart sock placed on an infant's foot to monitor the heart rate and pulse oxygen levels in the blood) as used to meet the patient's needs. The skilled nurse visit note, dated 9/16/2021, documented, after multiple emergency room visits, the family obtained an owlet for monitoring of the infant when in bed. The owlet did not get added to a Plan of Care update. 6. Patient #6 had a start of care date of 4/23/2021 and a discharge date of 6/30/2021. Clinical record review revealed: a. A verbal physician order, dated 4/26/21, ordered to decrease Lantus insulin from 40 units to 38 units every day. b. A verbal physician order, dated 4/28/21, ordered a change in frequency starting 5/2/21 for skilled nursing visits 2 times per week for one week, 1 time per week for 2 weeks and 2 as needed visits for falls, changes in skin, medications, or neuro status. c. A verbal physician order, dated 4/29/21, ordered to decrease Lantus insulin to 36 units every day. d. A verbal physician order, dated 5/4/21, ordered speech therapy to evaluate and treat the patient and to discontinue speech therapy after one visit. e. A verbal physician order, dated 5/5/21, ordered to decrease Lantus insulin 34 units every day. f. A verbal physician order, dated 5/7/21, ordered to collect a urinalysis for culture and sensitivity due to difficulty urinating. g. A verbal physician order, dated 5/12/21, ordered to decrease Lantus insulin to 30 units every day. h. A verbal physician order, dated 5/12/21, ordered nitrofurantoin 100 mg twice daily for 7 days. i. A verbal physician order, dated 6/14/21, ordered physical therapy 3 times per week for 1 week and then 1 time per week for one week. j. A verbal physician order, dated 6/16/21, ordered occupational therapy 2 times per week for one week and then one time per week for one week. k. A verbal physician order, dated 6/21/21, ordered occupational therapy visits one time per week for one week and two times per week for three weeks. l. A verbal physician order, dated 6/21/21, ordered physical therapy weekly for one week, and two times per week for three weeks. The Plan of Care, dated 4/23/21 to 6/21/21, failed to include an update with the changes of the added/changed orders. m. A verbal physician order, dated 6/23/21, ordered doxycycline 100 mg twice daily for 10 days. n. A verbal physician order, dated 6/23/21, ordered toprol XL 25 mg and instructed to take 1/2 tablet daily. o. A verbal physician order, dated 6/28/21, ordered take 10 units of Lispro insulin daily. p. A verbal physician order, dated 6/29/21, ordered ropinirole 0.25 mg at bedtime. q. A verbal physician order, dated 6/30/21, ordered speech therapy weekly for one week. The Plan of Care, dated 6/22/21 to 8/20/21, failed to include an update with the changes of the added/changed orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 7. Patient #7 had a start of care date of 1/2/2021. Clinical record review revealed: a. A verbal physician order, dated 6/7/21, ordered blood draw for basic metabolic panel, complete blood count, ant INR (international normalized ratio) on 6/14/21 and for the patient to resume bumex and potassium and continue the same dose of coumadin. b. A verbal physician order, dated 6/14/21, ordered no changes in coumadin dose and recheck INR in 2 weeks or around 6/28/21. The Plan of Care, dated 5/2/21 to 6/30/21, failed to include an update with the changes of the added/changed orders. c. A verbal physician order, dated 7/6/21, ordered to hold metoprolol, potassium, and bumex until Friday and draw basic metabolic panel and complete blood count on 7/9/21. d. A verbal physician order, dated 7/9/21, ordered skilled nurse or family to apply mepilex 3x3 dressing to coccyx pressure ulcer and change every 5 to 7 days. e A verbal physician order, dated 7/9/21, ordered nurse to perform INR blood draw on 7/12/21 or 7/13/21. f. A verbal physician order, dated 7/9/21, ordered physical therapy one time per week for one week. g. A verbal physician order, dated 7/12/21, ordered to hold metoprolol, potassium, and bumex with no restart date given. h. A verbal physician order, dated 7/13/21, ordered physical therapy three times per week for two weeks, then two times per week for two weeks. i. A verbal physician order, dated 7/13/21, ordered holding coumadin 7/13/21 and 7/15/21 and to give 5 mg on 7/14/21 and nurse to redraw INR on 7/16/21. j. A verbal physician order, dated 7/16/21, ordered to draw INR on 7/19/21, coumadin 5 mg daily and continue to hold bumex, metoprolol, and potassium. k. A verbal physician order, dated 7/19/21, ordered coumadin 5 mg on Tuesday, Wednesday, Friday, Saturday, Sunday and 10 mg on Monday and Thursday and redraw INR on 7/26/21. l. A verbal physician order, dated 7/22/21, ordered Levaquin 500 mg for 7 days. m. A verbal physician order, dated 7/26/21, ordered bumex 1 mg daily. n. A verbal physician order, dated 7/22/21, ordered Levaquin 500 mg for 7 days. o. A verbal physician order, dated 7/26/21, ordered potassium chloride ER 10 mEq (milliequivalents) twice daily. p. A verbal physician order, dated 7/29/21, ordered zinc oxide twice per day morning and evening to open area to right buttocks. q. A physician order, dated 8/3/21, ordered to increase coumadin to 10 mg on Monday, Wednesday and Friday and to take 5 mg all other days and recheck INR on 8/9/21. The Plan of Care, dated 7/1/21 to 8/29/21, failed to include an update with the changes of the added/changed orders The agency failed to ensure the Plan of Care was updated to include all patient care orders. 8. Patient #10 had a start of care date of 6/15/2021. Clinical record review revealed: a. A verbal physician order, dated 7/12/21, ordered skilled nursing two times per week for five weeks. b. A verbal physician order, dated 7/15/21, ordered simethicone 40 mg/0.6 milliliters (ml) and instructed patient to take 0.3 ml 9 times daily as needed for upset stomach. The Plan of Care, dated 6/15/21 to 8/13/21, failed to include an update with the changes of the added/changed orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 9. Patient #11 had a start of care date of 5/2/2021 and a discharge date of 6/29/2021. Clinical record review revealed: a. A verbal physician order, dated 5/2/21, ordered discontinuation of cozaar. b. A verbal physician order, dated 5/4/21, ordered clotrimazole-betamethasone 1 %-0.05% topical cream daily. c. A verbal physician order, dated 5/10/21, ordered nurse to draw basic metabolic panel at next visit and for patient to use tubagrips to bilateral lower extremities on in the morning and off in the evening. d. A verbal physician order, dated 5/12/21, ordered discontinuation of physical therapy. e. A verbal physician order, dated 5/28/21, ordered skilled nursing two times per week for one week. f. A verbal physician order, dated 6/4/21, ordered skilled nursing weekly for four weeks and 2 visits as needed for cardiopulmonary changes, falls, or wound changes. g. A verbal physician order, dated 6/4/21, ordered the nurse to draw a basic metabolic panel and hemoglobin at next visit before patient's doctor appointment on 6/10/21. The Plan of Care, dated 5/2/21 to 6/30/21, failed to include an update with the changes of the added/changed orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. The above findings for Patients #1, #3, #6, #7, #8, #9, #10, #11 and #12 were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff provided no additional 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, agency policy review, surveyor observation, patient/caregiver interview and agency staff interview, the agency failed to obtain physician orders for medications, services and treatments and provide services following such orders for 4 of 11 sampled patients (Patients #3, #8, #10 and #12). The agency reported a current patient census of 105 patients at the time of the survey. 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 the agency policy, titled Medications, Dispensing in the Home and updated 4/2019, the clinical record must include a completed physician order for ALL medications, both prescription and over-the-counter. Prescriptions that are new or modified can be identified through the prescription label without obtaining a verbal order. These medications will be noted in the electronic clinical record. 1. Patient #3 had a start of care date of 7/6/2021. Clinical record review, home visit observation and associated patient interviews revealed the following: a. The Plan of Care, dated 7/6/2021 to 9/3/2021, included physician orders for Acetaminophen 500 milligrams (mg) every 6 hours as needed for headache or pain. The physical therapy visit note, dated 7/19/2021, documented the patient reported inadvertently reporting Acetaminophen was used for headache/pain but in fact it was Headache Relief, which did include Acetaminophen 250 mg, Aspirin 250 mg and Caffeine 65 mg) 3-4 times daily as needed. On 8/11/2021 at 9:00 AM, the surveyor accompanied Staff H, Physical Therapist to Patient #3's residence. During the home visit, the patient interview reported he/she did not have any Acetaminophen in the home. The patient verified the only medication taken for headaches was Headache Relief tablets. The therapist added the over-the-counter medication to the agency medication profile but did not obtain a physician's interim order for the medication or obtain an order to discontinue the Acetaminophen originally added to the Plan of Care. b. The Plan of Care, dated 7/6/2021 to 9/3/2021, included physician orders for Vitamin D3 50 micrograms (mcg) 2000 iu (international units) two tablets every day. The physical therapy visit note, dated 7/19/2021, documented the therapist noted a prescription label ordering Vitamin D3 1250 mg 50,000 iu (international units) once weekly on Tuesdays. The therapist added the medication to the agency medication profile as allowed by agency policy when the prescription medication can be read on bottle label. During the home visit, the patient interview reported he/she had discontinued the original order for Vitamin D3 when the weekly dose was added. The therapist added the prescription medication to the agency medication profile but did not obtain a physician's interim order to discontinue the original dose of Vitamin D3 originally added to the Plan of Care. c. The Plan of Care, dated 7/6/2021 to 9/3/2021, lacked any physician orders for Benadryl. The physical therapy visit note, dated 7/28/2021, documented the therapist noted the patient had begun use of Benadryl 50 mg four times daily as needed for itching. The therapist added the over-the-counter medication to the agency medication profile but did not obtain a physician's interim order for the use of Benadryl. 2. Patient #8 had a start of care date of 12/7/2019. Clinical record review revealed the following: a. The Plan of Care, dated 5/30/2021 to 7/28/2021, included a physician order for Milk Thistle (over-the-counter medication) three 500 mg capsules once daily. The skilled nurse visit note, dated 7/21/2021, documented Patient #8 reported no longer using the Milk Thistle on a routine basis, switching to taking the medication only on an as needed basis. The nurse did not obtain a physician's interim order to discontinue the routine scheduled use of the Milk Thistle or obtain a physician's order for Milk Thistle on an as needed basis, to verify approved dosage and frequency of use. 3. Patient #12, an infant, had a start of care date of 8/5/2020 and was discharged from home health services on 7/28/2021. Clinical record review revealed: a. The Plans of Care, dated 8/5/2020 to 10/3/2020 and 10/4/2020 to 12/2/2020, included a physician's order for gas relief drops .3 milliliters (ml) every 4-6 hours. The agency medication profile documented the gas relief drops were discontinued on 11/29/2020. The clinical record lacked documentation of a physician order discontinuing the medication. b. The communication note, dated 9/10/2020, documented the emergency room staff directed the patient to use saline per nebulizer every 2 hours. The order for saline 0.9% 3 ml by nebulizer every 2 hours as needed was added to the Plans of Care dated, 10/4/2020 to 12/2/2020 and the 12/3/2020 to 1/31/2021. The agency medication profile documented the saline nebulizer treatments were discontinued on 1/1/2021. The clinical record lacked documentation of a physician order discontinuing the treatment. c. The Plans of Care, dated 8/5/2020 to 10/3/2020; 10/4/2020 to 12/2/2020; 12/3/2020 to 1/31/2021 and 2/1/2021 to 4/1/2021, included a physician's order for PolyVita 1 milliliters (ml) every day. The agency medication profile documented the Poly Vitamin was discontinued on 2/13/2021. The clinical record lacked documentation of a physician order discontinuing the vitamin. d. The Plans of Care, dated 8/5/2020 to 10/3/2020; 10/4/2020 to 12/2/2020; 12/3/2020 to 1/31/2021 and 2/1/2021 to 4/1/2021, included a physician's order for zinc oxide ointment topically 1-2 times daily to the buttocks as needed. The agency medication profile documented the zinc oxide ointment was discontinued on 2/16/2021. The clinical record lacked documentation of a physician order discontinuing the treatment. 4. Patient #10 had a start of care date of 6/15/2021. Clinical record review revealed: a. The Plan of Care, dated 6/15/2021 to 8/13/2021, included identified the patient was not taking/using any medications. b. The skilled nursing visit note, dated 6/22/21, documented a yeast rash in the patient's groin and the patient was using miconazole 7 on the rash. c. The clinical record lacked any physician's interim orders initiating the miconazole d. The skilled nursing visit note, dated 6/29/21, documented the addition of A and D ointment as a medication used by the patient for two denuded areas in patient's diaper region and noted the vital signs were faxed and the doctor was informed of the use of the A and D ointment. e. The clinical record lacked any physician interim orders initiating the A & D ointment. The above findings for Patients #3, #8, #10, and #12 were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff provided no additional 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 agency policy review, clinical record review, and agency staff interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 11 sampled patients (Patients #7 and #11). The agency provided services to 105 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's policy, titled Provider Orders/Plan of Care, dated 5/2021, a plan of care update will be sent when changes occur in the patient's physical and/or psychosocial condition or response to care, the clinician notifies the attending provider in a timely manner and documents the provider contact. Interview with the RN/Financial Manager on 8/11/21 at 3:00 PM revealed the agency has standardized guidelines for patient's vital signs to report to the physician if individual parameters are not identified and provided the surveyor with the guidelines. The agency standardized guidelines for physician notification for adults are as follows: systolic blood pressure low of 90 and high 170, diastolic blood pressure low of 50 and high of 90, pulse oximetry low of 88 and high of 100, heart rate low of 56 and high of 100, temperature of 100.5 or higher, and weight gain in 1 day of 1.5 pounds or 2.5 pounds in one week. 1. Patient #7 had a start of care date of 1/2/2021. Clinical record review revealed the following: a. The Plans of Care, dated 5/2/21 to 6/30/21 and 7/1/21 to 8/29/21, included the diagnosis of hypertensive heart disease with heart failure and identified the need for skilled nursing for assessment of vital signs including pulse oximetry. b. The skilled nursing visit note, dated 6/7/21, documented a sitting blood pressure of 102/48 and a standing blood pressure of 90/50. The note lacked notification of physician notification of the abnormal blood pressure readings. c. The skilled nursing visit note, dated 6/24/21, documented a pulse of 53. The note lacked notification of physician notification of the abnormal pulse reading. d. The skilled nursing visit note, dated 7/16/21, documented a standing blood pressure of 98/48. The note lacked notification of physician notification of the abnormal blood pressure reading. e. The skilled nursing visit note, dated 7/23/21, documented a sitting blood pressure of 98/46 and a standing blood pressure of 90/46. The note lacked notification of physician notification of the abnormal pulse readings. f. The skilled nursing visit note, dated 8/2/21, documented a sitting blood pressure of 104/52 and a standing blood pressure of 90/40. The note lacked notification of physician notification of the abnormal blood pressure pulse reading. g. The skilled nursing visit note, dated 8/5/21, documented a sitting blood pressure of 102/50 and a standing blood pressure of 90/40. The note lacked notification of physician notification of the abnormal blood pressure reading. 2. Patient #11 had a start of care date of 5/21/2021 and a discharge date of 6/29/2021. Clinical record review revealed the following: a. The Plan of Care, dated 5/2/21 to 6/30/21, included documentation of diagnosis of hypertensive chronic kidney disease and included orders for skilled nursing services to assess vital signs. b. The initial comprehensive assessment completed at the time of admission, documented a pulse of 54. c. A fax, dated 5/2/21, was sent to the physician with pulse range of 46-54 noted and no individualized parameters were received for the patient. d. The skilled nursing visit note, dated 5/6/21, documented a pulse of 45. The note lacked notification of physician notification of the abnormal pulse reading. e. The skilled nursing visit note, dated 5/10/21, documented a pulse of 45. The note lacked notification of physician notification of the abnormal pulse reading. f. The skilled nursing visit note, dated 5/13/21, documented a pulse of 55. The note lacked notification of physician notification of the abnormal pulse reading. g. The skilled nursing visit note, dated 5/18/21, documented a pulse of 51. The note lacked notification of physician notification of the abnormal pulse reading. h. The skilled nursing visit note, dated 5/25/21, documented a pulse of 45. The note lacked notification of physician notification of the abnormal pulse reading. i. The skilled nursing visit note, dated 6/2/21, documented a pulse of 47. The note lacked notification of physician notification of the abnormal pulse reading. j. The skilled nursing visit note, dated 6/4/21, documented a pulse of 48. The note lacked notification of physician notification of the abnormal pulse reading. k. The skilled nursing visit note, dated 6/9/21, documented a pulse of 44. The note lacked notification of physician notification of the abnormal pulse reading. The clinical record lacked evidence of the agency reporting changes in patient clinical findings or changes in patient needs to the physician. The above findings for Patients #7 and #11 were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff provided no additional information prior to the end of the survey.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, home visit observation and agency policy review, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 1 of 5 sampled patients (Patient #2) with home visit observations. The agency reported a current census of 105 patients. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: According to the agency policy, titled Injections, dated 3/2021, the nurse is to perform hand hygiene and apply gloves, provide privacy and position the patient to expose the area to be used, cleanse areas with a prep swab, administer subcutaneous injection, dispose of the needle and syringe in a sharps disposal box. Patient #2 had a start of care date of 4/14/2011. Clinical record review revealed the following: The Plan of Care (POC), dated 6/2/21 to 8/18/21, included physician orders for skilled nursing services and included orders for cyanocobalamin (Vitamin B12) 1000 micrograms (mcg) per milliliter (ml) with instructions for the patient to take 1 ml every 8 weeks and the nurse to administer the injection. During a home visit observation on 8/10/21 at 9:32 AM, the surveyor met with Staff D, Registered Nurse (RN), with the patient in the patient's home. The nurse wore a surgical mask and glasses and performed hand hygiene. The nurse verified the dosage of the Vitamin B12 matched the orders. Using a syringe the nurse drew up 1 ml of the medication. The nurse cleaned the injection site of the patient's left arm with an alcohol swab and allowed to dry. The nurse then administered the medication into the patients left arm and applied a Band-Aid to the patient's injection site. The nurse did not wear gloves for the administration of the injection. The syringe was disposed of into a sharps container and hands were sanitized. Failure to follow standard injection policy of wearing gloves placed the patient and nurse at risk for infection. On 8/10/21 at 2:00 PM, the surveyor asked the agency RN/Financial Manager for the agency's injection policy. RN/Financial Manager provided the policy to surveyor and revealed the policy states staff are to wear gloves for injections. The above findings were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and RN Supervisors. Agency staff 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: Based on clinical record review, the agency failed to ensure home health aides provided care to agency patients 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 4 sampled patients receiving home health aide services (Patients #2 and #8). The agency reported a current census of 105 patients at the time of the survey, including 29 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, 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: 1. Patient #8 had a start of care date of 12/7/2019. Clinical record review revealed the following: a. The Plan of Care, dated 5/30/2021 to 7/28/2021 and 7/29/2021 to 9/26/2021, included physician orders for skilled nursing visits daily for 1-3 hours in the morning and 45 to 60 minutes each afternoon 5 days per week to assist with bathing and personal care. b. The home health aide care plan/assignments, dated 6/12/2021, included direction to the aide to perform fingernail care (filing/trimming) twice a month and toenail care (filing/trimming) once monthly. c. The home health aide visit notes, dated between 6/1/2021 and 8/10/2021, lacked documentation indicating the home health aides trimmed/filed the patients fingernails or toenails. Each note completed during that time documented both tasks were omitted as the task was not applicable to the visit being performed. 2. Patient #2 had a start of care date of 4/14/11. Clinical record review revealed the following: a. The Plan of Care, dated 4/14/11, included physician orders for home health aide visits 3 times weekly to assist with bathing and personal cares. b. The home health aide assignment, dated 11/26/2020, included direction to the aide to perform and assist with shower twice a week using shower chair and perform complete sponge bath once a week. c. The home health aide visit notes, dated 7/12/21, 7/14/21, and 7/16/21, documented the aide performed a shower three times the week of 7/11/21. The aide failed to perform tasks as assigned or notify the nurse as to why the tasks were not completed as assigned. d. The home health aide visit notes, dated 8/2/21, documented the aide performed a shower one time the week of 8/1/21. The aide failed to perform tasks as assigned or notify the nurse as to why the tasks were not completed as assigned. e. The home health aide visit notes, dated 8/4/21 and 8/6/21, documented the aide performed a sponge bath two times the week of 8/1/21. The aide failed to perform tasks as assigned or notify the nurse as to why the tasks were not completed as assigned. The above findings for Patients #2 and #8 were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff 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: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to send a transfer summary to the physician and other health care professionals who would be providing care to the patient within 2 business days of a planned transfer or of becoming aware of an unplanned transfer for 1 of 2 sampled patients with a transfer where a summary should have been sent (Patient #6). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to agency policy, titled Transfer/Resumption of Care, dated 3/2021, transfer summaries must include the initial reason for the referral to the agency and a brief description of the patient's care and progress towards goals. The agency is to completed the transfer summary and forward to the receiving agency within 48 hours of knowledge of the transfer. Patient #6 had a start of care date of 4/23/21 and a discharge date of 6/30/21. Clinical record revealed: a. The Plan of Care, dated 4/23/21 to 6/21/21, documented the patient's diagnoses as cerebral vascular accident. b. An update to the comprehensive assessment for transfer to inpatient facility, dated 5/19/21, documented the patient was transferred to the inpatient facility due to a stroke. d. A transfer summary was completed by the nurse on 5/19/21. Interview on 8/10/21 at 9:45 AM with the Clinical Manager revealed the transfer summary is usually tagged in a communication note for the office staff to send. The nurse did not create the communication note so the transfer summary was never sent. The agency did not send the transfer summary as required by regulation. e. The physical therapy visit note, dated 6/30/21, documented the routine visit was changed to agency transfer/discharge after the agency was informed the patient was being transferred to an intermediate care facility (ICF). A transfer/discharge summary was completed and sent within 48 hours to the patient's primary care provider, however the summary was not sent to the intermediate care facility the patient was transferred to. The agency did not send the transfer summary to the individuals providing care for the patient as required by regulation. The above findings were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff 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: Based on clinical record review and agency staff interview, the agency failed to ensure authentication of staff documentation in each patient's clinical record included the date and time of the employee signature for 1 of 1 sampled patients receiving speech therapy services (Patient #6). The agency reported a current census of 105 patients at the time of the survey. Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: Patient #6 had a start of care date of 4/23/2021 and a discharge date of 6/30/21. Clinical record review revealed the following: a. The Plan of Care, dated 4/23/2021 to 6/21/2021, included orders for speech therapy services. b. The speech therapy initial assessment summary, dated 5/42021, was hand signed by the speech language pathologist (SLP) and dated; however, lacked a time of signature. During findings on 8/12/21 at 1:20 PM, the agency RN Financial Manager revealed speech therapy is the only discipline that has handwritten notes that are hand signed without an electronic date and time stamp. The above findings were reviewed with agency RN/Clinical Manager, RN/Financial Manager, and multiple RN Supervisors. Agency staff provided no additional information prior to the end of the survey.