Every finding on record at Delmar Gardens Home Care Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 11/01/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 11/01/2023. The provider had 286 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 policy review, record review, and interview the home health provider failed to complete the initial assessment within 48 hours of referral date in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy titled, "Care Planning Process," showed, in part, the initial assessment visit must be held within 48 hours of referral. RECORD/PATIENT #2: Review of the clinical record showed: -The patient was referred to home health services on 09/24/2023 for skilled services; -The patient's start of care assessment was completed 09/27/2023, 3 days after referral date; and -The provider failed to complete the initial assessment within 48 hours of the referral date. RECORD/PATIENT #4: Review of the clinical record showed: -The patient was referred to home health services on 09/27/2023 for therapy services; -The patient's start of care assessment was completed on 10/02/2023, 6 days after referral date; and -The provider failed to complete the initial assessment within 48 hours of the referral date. During an interview on 10/31/2023 at 2:40 PM, the home health clinical manager stated that he/she would expect the initial visit to be completed within 48 hours of the referral date.

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 policy review, clinical record review, home visit observation, and interview, the provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, but not limited to, two of three home visit observations (Records/Patients # 1 and #3). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy, dated revised “2/2023”, titled, “Medication profile” (policy number 3-030.1, 3-030.2, and 3-030.3), showed in part: - Upon admission to the agency, the admitting clinician will complete a written and electronic (EHR- electronic health record) medication profile to document the current medication regimen; - On an ongoing basis, as medications are added, the drug/drug interactions should be conducted by the nurse on the case or the designee within the office. Both will document this in the EHR; - The medication profile will be used as a care planning and teaching tool to assure the patient/caregiver and other clinicians understand the medication regimen; - The physician or designee will be informed to clarify any discrepancies, issues or incomplete/illegible/unclear orders identified among the patient’s medications; - The medication profile will be updated at each visit (if necessary) to reflect the most recent and most up to date medication list for the patient; - The original or non-carbon reproduction (NCR) copy will reside in the patient’s home folder and will be reviewed during medication reconciliations over the course of care; and - Patient medications that are taken in any other way than is ordered will be documented in the EHR and the physician will be notified. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the provider on 10/07/2023 after a skilled nursing facility stay with a primary diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and other pertinent diagnoses of essential hypertension (primary high blood pressure), and type II diabetes mellitus with hyperglycemia (a group of diseases that results in too much sugar in the blood- adult onset with high blood sugar levels). The patient received nursing, physical therapy and occupational therapy. Review of the medication list from the skilled nursing facility upon discharge provided to the provider showed, in part: - Humalog KwikPen (a prefilled insulin syringe that you dial to the amount of insulin to be given) insulin every six hours per sliding scale, subcutaneous, if blood sugar is 101 to 150 give two units, if blood sugar is 151 to 200 give three units, if blood sugar is 201 to 250 give 4 units, if blood sugar is 251- 300 give five units, if blood sugar is 301 to 350 give six units, if blood sugar is 351 to 400 give seven units, if blood sugar is 401 to 450 give “0” units, if blood sugar is 451 to 500 give ten units, if blood sugar before meal is greater than 100mg/dl give insulin based on the above; (Physician was notified on start of care of noncompliance with this sliding scale and this was not documented on the medication profile); and - Tresiba flextouch (a prefilled, once daily long acting insulin that you dial to the amount of insulin to be given) u (units)-100 100 u/ml (units per milliliter) (3 ml) insulin pen, 20 units subcutaneous, once a morning. (This was not listed on the medication profile and there failed to be documentation clarifying if this order was to continue or not). Observation and interview on 10/30/2023 at 12:45 PM, during the patient’s home visit observation showed the physical therapist reconciled the medications utilizing the patient’s medication profile from the patient’s home folder, comparing it to the patient’s medication bottles. The reconciliation showed the following discrepancies: - Famotidine (given to reduce stomach acid) 20mg (milligram) oral tablet, take one tablet daily. The patient was taking twice daily and stated that she/he had been “for some time”; - Spironolactone (a fluid pill that can be given to treat high blood pressure) 25mg take one tablet once a day. The patient had been taking ½ tablet and stated that he/she had been ever since obtaining it (the fill date on the bottle was 10/05/2023 and showed take ½ tablet daily); - Entresto (a medication used to treat heart failure) 24-26mg ½ tablet twice daily failed to be on the medication profile. The patient stated he/she had been taking it twice daily; - Humulin N (an intermediate acting insulin, used to lower blood sugar, that is slower to act and lasts longer than regular human insulin) insulin failed to be reconciled by the physical therapist. When the patient was asked about it, he/she stated that he/she took Humulin R (short acting insulin used to lower sugar quickly) and N sliding scale depending on where his/her blood sugar was, he/she normally took 10 units of Humulin R in the morning and 16-20 of N. The patient stated that he/she self-adjusted and didn’t have parameters, he/she had done that a long time and knew better how to control his/her blood sugars. (The medication profile in the home showed Humulin R/N per sliding scale and failed to list any parameters); and - Tresiba failed to be listed on the home medication profile. During an interview on 10/31/2023 at 2:50 PM the clinical manager stated that: - On admission the nurse puts on the POC the medications that were in the home; - Tresiba was on the referral but not in the home; - The nurse should have clarified it on admit if it was to be continued because it must have not been in the home; - He/she would have to check about the sliding scale, he/she believed it was stopped on admit and the medication list was never updated. No further information was provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the provider on 10/05/2023 after a skilled nursing facility stay with a primary diagnosis of essential (primary) hypertension (high blood pressure), and type II diabetes mellitus without complications (a group of diseases that results in too much sugar in the blood- adult onset). The patient received nursing, physical therapy, occupational therapy and aide services. Observation and interview on 10/31/2023 at 9:57 AM, during the patient’s home aide visit observation, the State Agent (SA) completed a medication reconciliation utilizing a current medication profile provided to the SA, compared to the patient’s medication list (hand written on notebook paper) in the home and with the medication bottles. The reconciliation showed the following discrepancies: - The medication profile provided by the provider showed Calcium citrate (calcium supplement) 250 mg elemental calcium, take two tablets once daily. The bottle showed calcium 600mg and the patient stated he/she took one daily; - The medication profile provided by the provider showed Vitamin D3 1250 mcg (micrograms) (50,000 international units) take one tablet once a day. The bottle showed vitamin D3 5,000 international units and the patient stated he/she took one daily; and - The patient’s medication list in the home included Propanolol (a medication given to treat high blood pressure, chest pain and irregular heartbeat) 10mg take one three times a day and omeprazole (medication used to treat heartburn) 20mg one daily which the patient stated he/she was taking in that manner. These failed to be listed on the provider’s medication profile. Per interview conducted during observation, the patient stated that: - No one reviewed his/her medications when they came; and - He/she had been given a list but was unsure where it was and utilized his/her own list. Per interview conducted during observation, RN A (who came to also observe the aide home visit observation) stated that: - He/she had not worked out in the field for a while now; and - When he/she worked in the field, he/she utilized the carbon copy form from the provider and kept it updated. He/she would do a medication reconciliation every visit.

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 policy review, clinical record review, observation, and interview, the provider failed to ensure that each patient’s written individualized plan of care (POC) included all the required elements, in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to adversely affect all patients served by the provider. Findings included: Review of the provider’s policy dated “revised 7/2014”, titled “Physician Orders/Plans of Care” (Policy number 8-017.1 and 8-017.2), showed in part: - Purpose: to outline the requirements for the complete, individualized diagnostic and therapeutic orders; - The contents of the diagnostic and therapeutic orders (POC) will include as appropriate: * The patient’s/client’s diagnosis; * A description of the treatment and/or procedure to be done, including when appropriate, the type, the frequency and duration; * Who is to perform the treatment or procedure; and * A description of equipment, if any, necessary in the provision of care. - For Medicare certified patients/clients, the plan of care must include the types of services and equipment required. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the provider on 10/07/2023 after a skilled nursing facility stay with a primary diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and other pertinent diagnoses of essential hypertension (primary high blood pressure), and type II diabetes mellitus with hyperglycemia (a group of diseases that results in too much sugar in the blood- adult onset with high blood sugar levels). The patient received nursing, physical therapy and occupational therapy. Review of the patient's POC dated 10/07/2023 to 12/05/2023 showed, in part: - Supplies: none (failed to include blood sugar monitoring device/supplies); - Nutrition: NCS (No concentrated sweets); - Humulin N (an intermediate acting insulin, used to lower blood sugar, that is slower to act and lasts longer than regular human insulin) 100u/ml (units/milliliter) inject 4 units subcutaneous four times a day (with meals and at bedtime); - SN (skilled nursing) teach regarding insulin administration, teach regarding proper foot care, and teach regarding s/s (signs and symptoms) of complications of diabetes; and - The POC failed to contain the frequency the blood sugar was to be checked and who was to check it. Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set; a standardized data collection tool), dated 10/07/2023, showed in part: - Under the Endocrine/Metabolic status: * Diabetes Mellitus Type 1; * Treatment- insulin; * Recent/usual BS (blood sugar) results- 175 fasting (in the morning before food); * Patient able to self-test- no; - Item M2001- drug regimen review marked yes, issues found during review; - Item M2003 Medication follow up: Did the agency contact a physician (or physician designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potentially clinically significant medication issues was marked yes; and - Narrative notes portion showed discharge instructions called for Humalog (a brand name fast acting insulin) sliding scale (insulin dose varies based on blood sugar levels), but patient refused to use the sliding scale insulin. He/she was continuing to use the vial and syringe system he/she was used to. Per interview conducted during observation, the patient stated that he/she adjusted his/her insulin dosage according to his/her blood sugar. He/she checked his/her blood sugar before meals and at bedtime. During an interview on 11/01/2023 at 8:53 AM, when discussing the blood sugar monitoring and supplies that failed to be on the POC, the clinical manager stated that: - Maybe it should have been included; and - They did have other education about the diabetes. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the provider on 10/05/2023 after a skilled nursing facility stay with a primary diagnosis of essential (primary) hypertension (high blood pressure), and type II diabetes mellitus without complications (a group of diseases that results in too much sugar in the blood- adult onset). The patient received nursing, physical therapy, occupational therapy and aide services. Review of the PT (physical therapy) initial visit dated 10/13/2023, showed in part: - Musculoskeletal assessment: Patient is toe touch weight bearing to right lower extremity. Patient is only able to bend right leg to 90 degrees, brace in place. Patient to wear it at all times; and -Narrative notes: patient is a “named age and gender” with diagnosis of meniscus tear (tear of the cartilage that acts as a cushion between the shinbone and thighbone). The POC failed to: -Contain the diagnosis- meniscus tear; -List weight bearing status; and -List the knee brace. Review of a multidisciplinary care plan with a printed date of 10/30/2023 showed, in part: - Impaired physical mobility: Discipline- Physical therapist assistant - Patient will demonstrate transfers modI (modified independent-requires an assistive device or aid) or less with appropriate WBing (weight bearing- the amount of weight a patient puts on an injured body part) status with LRAD (least restrictive assistive device); - The care plan failed to contain documentation of weight bearing status or the use of knee brace. Observation on 10/31/2023 at 9:57 AM, during the patient’s home visit, showed in part: - The patient failed to have a brace on his/her knee; - The provider’s aide questioned the patient where the knee brace was and the patient replied he/she did not have to wear it anymore. During an interview on 10/31/2023 at 1:59 PM, the clinical manager stated that: - The OASIS limits to six diagnoses; - The diagnosis of meniscus tear probably should have been higher so it would have printed out on the 485 (plan of care); and - He/she would have to check about the brace (no further information was provided).

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide services that are ordered by the physician as indicated in the plan of care in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy titled, "Care Planning Process," showed, in part, the following: -Prior to rendering any services to a patient, the clinician must carefully review the plan of care and/or interim order and provide services consistent with the orders; and -When documenting services and frequency of visits, each nurse or therapist must reference the plan of care and/or interim orders are being followed. RECORD/PATIENT #4: Review of the physician order dated 10/05/2023 for physical therapy (PT) visits two times a week for one week and then 1 time a week for 1 week. Review of the physician order dated 10/11/2023 showed an increase in physical therapy (PT) visits to two times a week for four weeks and then 1 time a week for 1 week. Review of the clinical record showed the following: -Two PT visits performed during the week of 10/08/2023; -One PT visit performed during the week of 10/15/2023 (one visit less than ordered); -Zero PT visits performed during the week of 10/22/2023 (two visits less than ordered); and -The provider failed to provide services as indicated in the plan of care. During an interview of 10/31/2023 at 2:40 PM, the clinical manager stated that he/she would have expected the plan of care to be updated with the new visit frequency and for those visits to have been made as ordered.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the provider failed to ensure the registered nurse (RN) or other appropriate skilled professional completed home health aide supervisory visits no less frequently than every 14 (fourteen) days in one of one applicable records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the aide care provided to all patients receiving aide services from the provider. Findings included: Review of the provider’s undated policy titled, “Responsibilities/Supervision of clinical services” (policy number 5-028.3) showed, in part: - Home health aide supervisory visits will be conducted on-site at least every two weeks by skilled personnel; and - At the discretion of the case manager, supervisory visits can be made in conjunction with or in his/her absence. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 10/05/2023 with a primary diagnosis of essential (primary) hypertension (high blood pressure) and other pertinent diagnoses of, but not limited to, Type II (two) diabetes (a group of diseases that results in too much sugar in the blood with an adult onset). Review of a verbal order dated 10/09/2023 showed: - Aide 1 wk 1 wk (one time a week for one week) start date 10/09/2023, end date 10/14/2023; and - Aide 2 wk 3 wk (two times a week for three weeks) start date 10/16/2023 , end date 11/04/2023. Further review of the clinical record showed: - The first aide visit note was dated 10/11/2023; and - The clinical record failed to contain any aide supervisory visits as of 10/30/2023, 19 (nineteen) days later. During an interview on 10/31/2023 at 2:59 PM the clinical manager stated that: - It looked like the aide supervisory visit should have been done last week; and - He/she was unable to find one documented.

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 policy review, clinical record review, and interview the provider failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services after discharge from the provider within five business days of the patient’s discharge in one of two discharge records reviewed (Record/Patient #5). This deficient practice has the potential to adversely affect the post discharge care of all patients served by the provider. Findings included: Review of the provider’s policy dated effective/reviewed/revised 03/2021, titled, “Discharge Summary” (policy number 8-019.1 and 8-019.2), showed in part: - All patients/clients discharged from the agency will have a discharge summary completed and filed in the clinical record; - Each clinician who provides care/services will complete a discharge summary at the time his/her discipline is discharged and agency discharge; - Communication with the physician will be documented in the medical record; and - A copy of the discharge summary will be provided to the patient’s client’s physician within five business days of the date of the order for discharge from the responsible physician. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 08/17/2023 with a principal diagnosis of hypertensive heart and kidney disease (high blood pressure resulting in strain on your heart and damage to the small blood vessels in your kidneys leading to your kidneys not filtering your blood as well as they should). Further review of the clinical record showed, in part: - A discharge OASIS (Outcome and Assessment Information Set; a standardized data collection tool) dated 09/07/2023; and - A discharge summary dated completed 09/07/2023, with a fax cover sheet to the primary care provider, dated 10/13/2023 (26 (twenty six) business days later). During an interview on 11/01/2023 at 8:50 AM the clinical manager stated that he/she did see that it was sent out late.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 02/24/2021. During the survey it was determined Delmar Gardens Home Care Inc. is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Delmar Gardens Home Care Inc was completed on 02/24/2021. The agency had 365 current patients. A Covid-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control 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: Based on policy review, record review, observation, and interview, the agency failed to ensure an accurate medication review and/or update of the patient's medication profile occurred when there were new/changed/discontinued medications in, but not limited to, two (Records/Patients #2 and #3) of five records reviewed. This deficient practice has the potential to affect the agency's ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Reconciliation," revised 05/2014 showed, in part: - Purpose: To define the agency's process of reconciling patient's medications at every visit; - Policy: Patients/clients will have a current, accurate medication profile in the clinical record reconciled at all times; - At every visit, the clinical will attempt to locate any list which may contain medications patient is to be taking. The list may be from other care settings, family, physician's office, the patient or the electronic health record (EHR); - The clinician will ask the patient to gather up all medications; whether or not in pill bottles, containers, or mediplanner, as well as over-the-counter medications or supplements; - The clinician must ask at least one probing questions of the patient/caregiver at each visit, examples of questions to ask include but are not limited to: "Do you use any types of creams or ointments on your skin?"; - The clinical will then proceed to individually read aloud all medications and dosages to the patient asking if the medication is currently a part of the medication regimen; - The clinician will enter only medications patient currently taking in the EHR if necessary; - If the patient has medications ordered by a physician but is omitting them or not taking them as directed, documentation must exist of what the medication is, dosage, frequency as well as notification to the physician office that the patient's not taking the medication correctly; - The clinician will compare the patient's current medication regimen to any list found which may contain medications the patient is to be taking; and - The clinician must notify the physician or physician's representative of the patient's current medication regimen; and - The clinician will make changes to the patient's medication regimen and EHR according to the physician's orders and educate the patient on those changes. RECORD/PATIENT #3: Review of the plan of care (POC) dated 02/02/21 through 04/02/2021 showed: - Admitted to service on 02/02/2021; - Physical therapist (PT) A recorded a list of current medications; - Medications included but not limited to Polyethylene Glycol 3350 (a mild laxative to treat constipation) powder, 17 grams (gm) daily and Melatonin (a sleep medication) 5 milligram (mg) one tablet at bedtime (HS). Review of clinical notes dated 02/09/2021, 02/11/2021, and 02/18/2021 showed: - Physical therapy assistant (PTA) B recorded medications reconciled without issue, no medication changes since last visit, no observed issues, and no medications taught. Review of the agency's current medication profile dated 02/22/2021 showed: - Polyethylene Glycol 3350 powder, 17 gm daily; and - Melatonin 5 mg one tablet at HS. A home visit observation on 02/23/2021 at 10:00 AM showed: - Physical therapist (PT) A individually read aloud all medications and dosages to the patient asking if the medication was currently a part of the medication regimen; - The caregiver and the patient stated dialysis discontinued Polyethylene glycol two weeks ago; - The caregiver said he/she could not find Melatonin 5 mg tablets and bought 3 mg tablets but the patient did not take the Melatonin because it did not help the patient to sleep; dialysis told the patient to discontinue the Melatonin; - PT A found a bottle of Daily Vite (a vitamin supplement) and asked the caregiver and patient if the patient took the vitamin; - The caregiver stated the patient started the vitamin on 02/03/2021; - PT A instructed the patient/caregiver that the Melatonin was as needed and he/she could take up to three tablets at HS. During an interview on 02/24/2021 at 9:00 AM, the clinical manager stated: - Medications should be reconciled with each clinician visit; - The medication profile and the EHR should be updated and clinical notes should indicate changes in medications the patient is taking; and - The physician should be notified when medications are changed, discontinued, or added and orders need to be written. RECORD/PATIENT #2: Review of the POC dated 02/04/2021 through 04/04/2021 showed: - The start of care (SOC) date was 02/04/2021; and - Diagnoses included but not limited to: Polyneuropathy (multiple peripheral nerves become damaged), type 2 diabetes (disorder involving resistance to secrete insulin) and hypertension. Review of the medication list faxed from the patient's physician office on 02/10/2021 at 3:37 PM showed the agency did not address/reconcile the following medications: - Acetaminophen 500 mg, one tablet every four hours for mild pain; - MethIMAzole (used to treat hyperthyroidism) 5 mg take two tablets by mouth daily; - Metoprolol (lowers high blood pressure and helps prevent strokes) 25 mg two times a day; and - Potassium chloride (to prevent or treat low levels of potassium) 20 milliequivialent (mEq) daily with breakfast. Review of the agency's patient medication profile report dated 02/23/2021 showed: - MethlMAzole 5 milligrams (mg) one tablet daily by mouth; and - Icy hot extra strength external cream 10-30%, one application as needed "EX" for pain on bilateral knees/wrists (no instruction on how often to use). During a home visit observation on 02/23/2021 at 10:45 AM, review of the patient's bottles of medications showed methIMAzole 5 mg take two tablets by mouth daily. During an interview on 02/24/2021 at 8:46 AM, the clinical director stated: - The physician's office sent the patient's list of medications on 02/10/2021; - He/she had no information to show the medications were addressed/reconciled; and - He/she expected the order for icy hot to include frequency of use.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, and interviews, the agency failed to ensure each patient received written information related to visit schedule/instructions in two of three applicable cases (Record/Patient #2 an #3). This deficient practice has the potential to affect all patients admitted to the home health agency. Findings included: Review of the agency's policy titled, "Patient Rights and Organization Ethics," dated October, 2002, showed: - The right to be notified in advance about care to be furnished and frequency of proposed care; and - The right to be notified of changes in plan of care before the change is made. RECORD/PATIENT #3: Review of the plan of care dated 02/02/2021 through 04/02/2021 showed: - Physical therapy (PT) 1 x day x 1 day (one day for one week) week of 02/02/2021. Review of a supplemental order dated 02/05/2021 showed: - PT 2 x week x 3 weeks beginning week 02/07/2021 and discontinue on 02/27/2021. During a home visit observation on 02/23/2021 at 10:00 AM, the information provided to the patient by the home health agency was reviewed. The information provided showed a PT visit on 02/02/2021 for the initial evaluation of the patient and failed to include a schedule for further PT visits. The agency failed to ensure the patient received written information related to the visit schedule, including frequency of visits for PT. RECORD/PATIENT #2: Review of the plan of care (POC) dated 2/04/2021 through 04/04/2021, showed physical therapy to visit 1w1 (1 time a week for 1 week) and 2w2 (2 times a week for 2 weeks). Review of the supplemental order dated 02/21/2021, showed physical therapy to visit 2w2 and the social worker to visit 1w1. During the home visit observation on 02/23/2021 at 10:45 AM, the information provided to the patient by the home health agency was reviewed. The information provided showed a physical therapy assistant and social service visit on 02/12/2021 and failed to include a schedule for other physical therapy and social service visits. The agency failed to ensure the patient received written information related to the visit schedule, including frequency of visits for physical therapy and social services. During an interview on 02/24/2021 at 8:46 AM, the clinical manager stated the patient has the right to know the day and frequency of scheduled visits.

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 policy review, record review, and interview, the agency failed to ensure a completed comprehensive discharge summary to include all necessary components was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency/services within five business days of the patient's discharge in two (Record/Patient #4 and #5) of two discharge records reviewed. This deficient practice has the potential to affect the post-discharge care of all patients served by the agency. Findings included: Review of the agency's policy titled, "Discharge Summary," and dated March, 2020, showed: - Purpose: To define the requirements for documentation of patient/client discharged from the agency; - The discharge summary will include: * Date of discharge, the date the physician and patient/client are informed of discharge; * Reason for discharge including if applicable, the name of the organization to which the patient/client will be transferred/discharged; * Status of problems identified at admission and during provision of care and resolution of identified problems; * Overall status of the patient/client; * A summary of the care or services provided; * Instructions and referral provided to the patient/client; * Existence of any advance directives; - The discharge OASIS (a mandated assessment tool) or summary and other relevant clinical record document will be completed and submitted to the organization within 24 hours of discharge or the next business day; - Communication with the physician will be documented in the medical record; and - A copy of the discharge summary will be provided to the patient's/client's physician within five days. RECORD/PATIENT #5: Review of the patient's Plan of Care (POC) dated 10/24/2020 through 12/22/2020 showed: - Diagnoses included: Diabetes mellitus (elevated blood sugar levels to be treated with insulin or other diabetic medications) with hyperglycemia (elevated blood sugar levels), tendinitis (irritation or inflammation of a tendon) of the right rotator cuff, venous insufficiency (lack of blood flow), heart failure, and end stage renal disease, and dialysis (a treatment for kidney failure that rids the body of unwanted toxins, waste products and excess fluids by filtering the blood when the kidneys fail); - Skilled nurse (SN) 1 time per week (w) x 2 weeks (w); - Physical therapy (PT) evaluation week of 10/25/2020 for fall risk; - Occupational therapy (OT) evaluation week of 10/25/2020 for self-care deficit; and - Discharge to self or assisted living facility (ALF) care by 12/22/2020. Review of supplemental physician's order sheet dated 11/01/2020 showed: - OT 2 x w x 4 w. Review of the team care plan (a part of the physician orders) dated 10/24/2020 showed: - PT 2 x week x 3 w. Review of the OT Discharge from Agency OASIS dated 11/25/2020 recorded by the occupational therapist showed: - No comprehensive assessment to include all the necessary components sent to the receiving healthcare professional. Review of the OT Clinical Note dated 11/25/2020 showed: - No comprehensive assessment or all the necessary components to include the patient's current medication list to be sent to the receiving healthcare professional. Review of the Supplemental Order sheet dated 11/12/2020 showed: - Discharge patient from the agency; all current/future orders for home care are canceled; - Did not include a comprehensive assessment for all disciplines who provided treatment/services to the patient and all necessary components to include the patient's current medication list; and - The shipped date recorded was 12/03/2020, eight days after the patient's discharge home. During an interview on 02/24/2020 at 8:15 AM, the clinical manager (CM) stated: - Orders for discharge are generated by the last discipline in the home and the orders go to medical records; - Medical records sends the discharge summary to the physician and stamps the date summary with "Shipped _____" date; - OT was the last discipline in the patient's home; - No comprehensive summary to include all disciplines was written by the occupational therapist; - The shipped discharge supplemental order sheet was sent late, eight days after the patient was discharge from the agency; - He/she was told that each discipline could write and send individual discharge summaries when a discipline discharged the patient from their service; - The last discipline in the home only wrote a summary for that discipline upon discharge; - Medication lists were not sent upon discharge to the physicians; and - He/she did not have a list of all the necessary components to be included in the discharge summary sent to the healthcare professional. RECORD/PATIENT #5: Review of the patient's POC dated 10/16/2020 through 12/14/2020 showed: - Start of care date 10/16/2020; - Diagnoses included but not limited to: open wound to left lower leg, atrial fibrillation (a quivering or irregular heartbeat), and congestive heart failure (heart muscle doesn't pump as well as it should); and - Skilled nursing services. Review of the Discharge Case Conference Report dated 01/07/2021 showed: - No current medication list included with the discharge summary by the skilled nurse.