Every finding on record at Faith Healthcare, LLC

An extended survey for Medicare certification for Faith Home Healthcare was completed on 01/26/2022. The agency had 119 current patients. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey completed on 01/26/2022. One standard level deficiency was identified.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on the agency's policy and emergency preparedness plan review, the agency failed to maintain an updated emergency preparedness communication plan. The communication plan failed to include accurate names and contact information for staff. The deficient practice has the potential to affect all patients on service with the home health agency. Findings included: Review of the agency's undated policy titled "emergency implementation plan" showed in part that "DON/ADON to issue emergency plan when necessary, will notify all staff of plan via email, if electronic system down will notify via phone if both systems down staff report to office". Review of the agency's emergency implementation plan showed an attached staff list with contact telephone numbers. The emergency implementation plan staff list was compared with the current staff list. The current staff list showed six current clinicians that were not included in the emergency implementation plan list and 12 staff that were no longer working for the home health provider. During an interview on 01/25/2022 at 2:20 PM, the administrator stated that he/she forgot to update the emergency preparedness manual with the updated employee list.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on review of the Outcome and Assessment Information Set OASIS-D Guidance manual and record review, the agency failed to ensure that the encoded OASIS data accurately reflected the patient's status at the time of assessment in one of five full records reviewed (Record/Patient #2). The deficient practice has the potential to affect all patients served by the home health provider. Review of the Outcome and Assessment Information Set OASIS-D Guidance manual, effective January 1, 2019, showed that: -Diagnoses are listed in the order that best reflects the seriousness of each condition and supports the disciplines and services provided; and - Active diagnoses are diagnoses that have a direct relationship to the patient’s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of assessment. Do not include diseases or conditions that have been resolved or do not affect the patient’s current functional, cognitive, or mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of assessment. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/12/2021 with: - A primary diagnosis of type 2 diabetes (DMII) (Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems); - Secondary diagnoses of dysphagia (difficulty swallowing), dementia, history of blood clots, and long term use of anticoagulants; and - The patient resided in his/her adult child’s home. Review of intake fax documentation dated 12/08/2021 showed that: - The patient was discharging from a memory care unit on 12/10/2021 and would require physical therapy (PT), occupational therapy (OT), and nursing services; and - The patient was on a regular, mechanical soft diet. Review of the comprehensive nursing assessment dated 12/12/2021 documentation showed that the patient was a diet controlled diabetic who did not own a glucometer. Review of the physical therapy evaluation dated 12/13/2021 showed that: - The patient required maximum assistance to transfer; - Was non-ambulatory and required a wheelchair; and - Required assistance to change from a sitting to standing position. Review of the occupational therapy evaluation dated 12/16/2022 showed that: - The patient required assistance for all sit-to-stand activities, and - Required moderate assistance to maintain a standing position. Review the plan of care (POC) with certification dates from 12/12/2021 to 02/09/2022 showed that: - The primary diagnosis for care was DMII; - Nursing services were to make a total of five visits for: * Assessment of vital signs, pulse oximetry (a test used to measure the oxygen level of the blood), pain, all body systems, knowledge of disease processes and its associated care and treatment, medication regimen knowledge, medication compliance; and signs and symptoms of complications necessitating medical attention at each visit; * Education of self-management of disease processes to include DMII, coronary artery disease and any other co-morbidities where deficits exist, standard precautions, discharge needs and planning; - Physical therapy services were to make a total of five visits for: * Fall prevention and safety including keeping area clear around bed/commode and adequate lighting; * Caregiver training and education; * Therapeutic exercise for lower extremity strengthening including supine and seated exercises; * Static and dynamic balance training; * Transfer training: * Pain management education including non-pharmacological pain management techniques; * Core stabilization exercises, and * Education on foot care for diabetes; - Occupational therapy services were to make a total of six visits for: * Establishment of home exercise program; * Patient education; * Pulse oximetry; * Adaptive equipment and durable medical equipment training; * Therapeutic exercise; * Neuromuscular re-education balance safety training, fall risk, transfer, and therapeutic activities; * Activities of daily living training for dressing and toileting; * Wheelchair management/mobility; * Pressure relief; * Energy conservation; * Ergonomics; and * Cognitive training; - The POC failed to list a primary diagnosis that supported the disciplines and services provided during the episode of care. On 01/26/2022 at 11:25 AM the administrator stated that: - DMII was not an appropriated primary diagnosis for this episode of care; and - That they were using an independent company to do the diagnosis coding and had been having issues with coding. Findings Included:

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on review of current patient bill of rights, home visit observation, and interview, the agency failed to inform and obtain written consent in advance of treatment of the discipline that would furnish care in one (Patient #1) of five full records reviewed. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all agency patients/representatives. Findings included: Review of the agency’s current “Patient Bill of Rights”, dated 12/2021 provided by the agency’s administrator on 01/24/2022, showed, in part: - Each patient shall have the right to be advised in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished; and - Receive proper written notice, in advance of a specific service being furnished. RECORD/PATIENT #1 Review of the plan of care dated 12/22/2021 to 02/19/2022 showed orders for skilled nursing, occupational therapy and physical therapy. Review of the home health consents and agreements dated 12/22/2021 showed the patient signed services/financial responsibility for a physical therapist and occupational therapist. Review of the skilled nurse notes showed the following: - On 12/23/2021, showed a registered nurse (RN) provided a skilled nurse evaluation; - Review of the skilled nurse notes dated 112/28/2021, 01/05/2022, and 01/11/2022 showed a licensed practical nurse provided routine visits; and - Review of the skilled nurse note dated 01/18/2022 showed a RN provided a routine visit. Review of the medical record failed to show an advance consent for service and financial responsibility for RN and LPN visits. During a home visit on 01/25/2022 at 9:00 AM, review of the patient’s current patient handbook showed a home health consent and agreement for physical therapy and occupational therapy services. The handbook did not include an updated consent for skilled nursing. During an interview on 01/26/2022 at 8:50 AM, the administrator stated that skilled nursing was ordered after the start of care. The agency obtained verbal consent but not written consent, in advance, of skilled nursing services. Findings Included:

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on policy review and record review, the agency failed to ensure patients were accurately advised of the state toll free home health telephone hot line contact information in five (Records/Patients #1, #2, #3, #4 and #5) of five records reviewed for patient rights . The deficient practice has the potential to affect all of the agency patients. Findings included: Review of the agency's undated policy titled "PATIENT BILL OF RIGHTS AND RESPONSIBILITIES" showed in part that "The Registered Nurse or Licensed Therapist responsible for the admission of the patient to home healthcare" shall "Instruct the patient/family/caregiver in the availability of the state toll-free Home Health Hotline, its hours of operation and its purpose". Review of the consent for home health service, signed by patients or representatives on the start of care for active Records/Patients #1, #2, #3, #4 and #5 showed "The Agency's complaint process and state's toll free hotline". The phone number provided to the patient in the consent was not the Missouri home health telephone hot line. On 01/25/2022 at 11:45 AM the phone number provided on the consent was called. The number was for a department of health in Arizona, which is not the state where the patients' reside or the home health provider operates. During an interview on 01/25/2022 at 2:15 PM, the administrator stated that the home health agency owners previously had home health agencies in Arizona, and the phone number on the consent did not get updated to Missouri's number.

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, home visit observation, Missouri State Board of Registration for the Healing Arts letter review, and interview, the agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, one (Record/Patient #1) of three home visit observations (Example #1). The home health agency uses therapists to perform medication review in therapy only cases (Example #2). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, "Medication Management-Patient Information," showed, in part, the following: - Purpose: To facilitate continuity of care, treatment and/or services for Agency patients by providing accurate and comprehensive information about patients’ medications; - To create and maintain an accurate medication history and current medication profile while the patient is receiving care, treatment and/or services from Agency; and - The patient’s medications are reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient’s response to the medications are conveyed to the ordering physician and Case Manager. RECORDS/PATIENTS #1: During the patient's home visit observation on 01/25/2022 beginning at 9:00 AM showed the following discrepancies with the agency's current medication profile: - There was a bottle of acetaminophen 500 mg. The medication profile showed acetaminophen 325 mg two tablets every six hours as needed for mild pain; - The medication list showed acetaminophen –oxycodone 325 milligram (mg)-oxycodone (used to treat moderate to moderately severe pain) 5 mg take one to two tablets by mouth every six hours as needed for pain, started 01/03/2022 and ended 01/10/2022. There was no physician order for this medication; - A bottle of bisacodyl (laxative) 5 mg. The medication profile did not include bisacodyl; - The medication profile showed clonazepam (sedative) 0.25 mg one tablet up to four times daily as needed for hallucinations; - A prescription bottle showed Furosemide (diuretic) 40 mg one tablet every morning for fluid and filled 01/06/2022. The medication profile showed Furosemide discontinued 12/30/2021; - A prescription bottle showed losartan (antihypertensive) 100 mg one tablet daily for blood pressure and filled 12/22/2021. The medication profile showed losartan 25 mg two tablets every day; - The medication list showed Oxycodone (used to treat moderate to severe pain) 5 mg one tablet every four hours as needed for moderate pain; - A prescription bottle showed pravastatin sodium (treats high cholesterol and triglyceride levels) 400 mg half tablet at hour of sleep and filled 10/27/2021 The medication profile did not include pravastatin; and - A prescription bottle showed trazadone (antidepressant and sedative) 100 mg two tablets at hour of sleep as needed for mood or sleep and filled 11/22/2022. The medication profile did not include trazadone. During an interview during the home visit observation on 01/25/2022, beginning at 9:00 AM the patient/caregiver stated that: - The patient now takes bisacodyl for constipation; - He/she no longer takes clonazepam and oxycodone; and - He/she takes furosemide. During interview on 11/26/2022 at 8:50 AM, the administrator stated that they were waiting for clarification on the patients medication discrepancies found during the home visit on 01/25/2022. There was no physician order for acetaminophen-oxycodone 325 mg-5 mg and could have been entered by mistake. The registered nurse reconciles the medications. There was no additional information provided. Findings Included:

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 and clinical record review, the agency failed to ensure that each patients' written individualized care plan included relevant and required elements in, but not limited to, two (Records/Patients #1 & #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/12/2021 with: - A primary diagnosis of type 2 diabetes (DMII) (Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems); - Secondary diagnoses of dementia, dysphagia (difficulty swallowing), history of blood clots, and long term use of anticoagulants; and - The patient resided in his/her adult child’s home. Review of intake fax documentation dated 12/08/2021 showed that: - The patient was discharging from a memory care unit on 12/10/2021 and would require physical therapy (PT), occupational therapy (OT), and nursing services; - The patient would require a hospital bed and a standard wheelchair; - The patient was on a regular, mechanical soft diet; and - The patient required that the head of the bed be elevated to 45 degrees related to dysphagia. Review of the comprehensive nursing assessment dated 12/12/2021 documentation failed to address dysphagia, the use of a hospital bed, and the need to keep the head of the bed elevated 45 degrees. Review the plan of care (POC) with certification dates from 12/12/2021 to 02/09/2022 failed to contain: - A hospital bed as a required durable medical equipment for the patient, and - Interventions to keep the head of the bed elevated 45 degrees. On 01/26/2022 at 11:25 AM the administrator was notified of the above findings and no further information was provided prior to survey exit. Findings included: Review of the agency's undated policy titled, "Care Planning," showed: - To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes; - The plan of care is developed and documented by the registered nurse or physical therapist if a Physical Therapy-only admission, in coordination with the patient/family/ significant other; - When a patient is receiving more than one service, each discipline develops a plan of care; - Each discipline, i.e. nursing, therapies, social work including contracted services, develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/admission visit; - Each discipline to operate within their scope of practice under the state guidelines to develop a plan of care that centers around the patent; - The Case Manager/Director of Nursing is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient’s needs and clinical status. It promotes positive outcomes; and - The healthcare team member updates the plan of care as necessary. RECORD/PATIENT #1 Review of intake fax documentation dated 12/20/2021 showed that: - The patient experienced hallucinations and it could be from pain medications (from pain medications or not getting them); and - The patient reported seeing bugs and hallucinating, seeing a float that he/she believed got away from the parade. He/she reported not getting pain medications overnight and recently received pain medications and feeling much better. The comprehensive assessment dated 12/22/2021 at 7:48 AM showed the patient at risk for hospitalization due to decline in mental, emotional, or behavioral status in the past three months. Review of the POC dated 12/22/2021 through 02/19/2022 showed: - Patient at risk for hospital and emergency room due to decline in mental, emotional, or behavioral status in the past three months; - Clonazepam, disintegrating 0.25 milligrams (mg) one tablet up to four times daily as needed for hallucinations; and - The plan of care did not include specific individualized interventions and education of Clonazepam and hallucinations. Review of a licensed practical nurse (LPN) visit note dated 01/11/2022 at 2:14 PM showed that: - The patient’s blood pressure was slightly elevated and the patient was educated on checking blood pressure every day as advised by the cardiologist; - The patient reported he/she was supposed to be checking his/her weight daily, skilled nursing provided the patient a scale and advised of parameters for weight for post-surgery monitoring; and - The plan of care did not include specific interventions to monitor blood pressure and weights daily and weight parameters. During an interview during the patient's home visit observation on 01/25/2022 beginning at 9:00 AM showed the following: - The patient/caregiver stated the patient no longer took Clonazepam and no hallucinations since admission to the agency; - The patient/caregiver stated they record the patient’s weight and blood pressure daily; and - Licensed practical nurse A educated the patient’s caregiver to notify the cardiologist if the patient had a weight gain of five pounds a week or two pounds a day.

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 policy review and observation, the home health agency failed to follow accepted standards of practice for infection prevention in two (Records/Patients #2 & #3) of three patients sampled where home visit observations were completed. The deficient practice has the potential to affect all patients served by the home health agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/12/2021 with: - A primary diagnosis of type 2 diabetes (DMII) (Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems); - Secondary diagnoses of dysphagia (difficulty swallowing), dementia, history of blood clots, and long term use of anticoagulants; and - The patient resided in his/her adult child’s home. During a home visit observation on 01/25/2022 at 11:50 AM, the clinician: - Cleansed her hands using sanitizing gel; - retrieved her supplies (which were in a zip lock bag) from the clinical bag, and zipped up the bag; - Placed her supplies on a drape resting on an upholstered chair, and placed the empty zip lock bag directly on the upholstered chair; - Used and cleaned her supplies and placed them on a different drape resting on an upholstered chair; - Retrieved paperwork from under the two drapes causing the soiled drape to slide on top of the cleaned equipment on the second drape; - cleansed her hands using a sanitizing gel; - wrapped the supplies in the soiled drape that was resting on the upholstered, and placed the supplies, and soiled drape, into the zip lock bag that was resting on the upholstered chair; and - Failed to cleanse the outside of the zip lock bag prior to placing inside of the clinical bag. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/01/2021 with a primary diagnosis of stage three pressure ulcer of the right and left buttock (Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 3 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous (fat) tissue layer. During a home visit observation on 01/26/2022 that began at 08:00 AM, the clinician had the patient sign his/her tablet (using his/her finger), the clinician failed to cleanse the tablet before leaving the home. Findings Included: Review of the agency's undated policy titled "Bag Techniques" showed in part the following: - The staff should "maintain a clean nursing bag and prevent transmission of infection to patients"; and - "Reusable equipment is cleaned using alcohol, antiseptic spray and/or soap and water as appropriate.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure all skilled professionals providing service conducted ongoing assessments of the patient in, but not limited to, one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect the assessment needs for all agency patients. Findings included: Review of the agency's undated policy titled, "Patient Assessment Functions and Qualifications," showed that: - To provide appropriately qualified staff to meet the patient’s initial and changing needs for appropriate care, treatment and/or services identified during the referral, assessment and/or reassessment process; and - Agency provides care and modifies care, treatment and/or services to meet the patient’s needs as identified through assessments, reassessments. Review of the plan of care dated 12/22/2021 to 02/19/2022 showed that: - Sebaceous cyst (a small, slow-growing, noncancerous bump under the skin); - Skilled services included nursing, physical therapy and occupational therapy; - Skilled disciplines to assess, perform, and instruct on wound healing for cyst on back; and - Skilled nurse will provide wound care weekly and the patient’s caregiver will provide wound care weekly. Review of the physical therapy assistant (PTA) visit note dated 01/03/2022 at 10:24 AM showed that: - The integumentary assessment showed a cyst to the left of the lumbar spine, the patient had a cyst that opened up, and the wound base had eschar and redness around the peri-wound; - The integumentary documentation/teaching showed the patient has an area on right buttock that is bandaged and the patient thinks it is a boil that has ruptured and the patient plans on having the doctor assess the area today at his/her appointment; - Care was coordinated/collaborated with physical therapist; and - The documentation failed to include a complete assessment of the patient's right buttock. During an interview on 01/26/2022 at 8:50 AM, the administrator stated that the cyst on the patient’s right buttock was an error. No additional information was provided. fffffffffffff

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, clinical record review, and interview, the agency failed to provide skilled nursing services as ordered by the physician on the plan of care (POC) in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the quality of nursing care to all patients served by the agency. Findings included: RECORD/PATIENT #5: Review of the POC, dated 10/30/2021 to 12/28/2021, showed skilled nursing one visit for one week, effective 11/21/2021. Review of the clinical record showed no skilled nursing the week of 11/21/2021. During an interview on 01/26/2022 at 9:53 AM, the administrator stated that skilled nursing missed a visit the week of 11/21/2022 and the physician was not notified. ffffffffffffffffff

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on policy review and record review, the home health agency failed to ensure licensed practical nurse services were appropriately supervised by a registered nurse for patient health needs and status in one (Record/Patient #3) of five records reviewed. The deficient practice has the potential to affect all patients served by the home health provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/01/2021 with diagnoses, including but not limited to: - Chronic embolism (obstruction) and thrombosis (blood clot) of the deep veins of left lower extremity; and - Chronic kidney disease (the kidneys are damaged and fail to work properly and may cause swelling of the legs, feet or ankles). Review of the plan of care, with certification dates of 12/31/2021 through 02/28/2022 showed that: - The patient was to take warfarin (a medication used to lengthen the time it takes the body to form blood clots; and the nurse was to obtain a pro-time with internationalized ratio (INR) (a test used to check the time it takes for blood to clot) weekly on Fridays, and call the results to the physician; and - Contact the physician if the patient’s weight was less than 280 pounds or greater than 290 pounds. Review of licensed practical nursing visit dated 01/14/2022 failed to contain documentation that the physician or registered nurse were notified of the client’s reported weight of 296. Review of the general notes report provided by the administrator on 01/26/2022 at 11:30 AM showed that: - The licensed practical nurse (LPN) had called the physician’s office on 01/14/2022, 01/17/2022, and 01/19/2022 to get orders for when to obtain the next pro-time INR, and did not get a return call from the physician’s office; - On 01/21/2022 the patient had reported he/she received a call from his/her physician directing him/her to have the pro-time INR rechecked in two weeks, on or around 01/28/2022. The LPN documentation showed that he/she called the physician’s office to verify the patient’s report and had not received a return call from the physician’s office; - On 01/24/2022 the LPN documentation showed that he/she had called the physician’s office once again to clarify the pro-time INR orders for the patient, and did receive orders for the test; - The clinical record failed to contain documentation that the LPN had notified the registered nurse that he/she was not getting return calls with orders for follow up pro-time INR testing from 01/14/2022 to 01/24/2022. Findings Included: Review of the undated agency's policy titled "Employee Supervision" showed a Licensed Practical Nurse will be supervised by a Registered Nurse at least every 60 days and "as necessary" based on patient acuity.

A complaint investigation (complaint 61289 and 61294) was completed at Faith Home Healthcare. The agency's total patient census was 115. The complaints are substantiated. One or more of the allegations reported are verified and deficiencies are cited related to the allegations being investigated. During the complaint investigation one condition-level deficiency was identified as follows: - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality Care

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the agency patient handbook provided to patients at time of admission to service, and interview, the agency failed to provide the correct administrator’s name to patients in order to receive complaints. This deficient practice has the potential to affect the ability to file complaints for all of the agency patients. Findings included: Review of the document revised 07/2021 and titled, "Faith Home Healthcare Patient Handbook,” showed the name of the previous administrator (who resigned 11/12/2021) as the person to contact to file complaints. The previous administrator’s name appears on, but not limited to, pages 4, 11, and 17 of the handbook. During a telephone interview on 11/23/2021 at 4:16 PM Record/Patient #5 stated that his/her, “Patient Handbook,” showed the name of the previous administrator as the person to contact to file complaints. During a telephone interview on 11/23/2021 at 4:24 PM Record/Patient #6 stated that his/her, “Patient Handbook,” showed the name of the previous administrator as the person to contact to file complaints. The findings were reviewed with the administrator on 11/23/2021 at 4:33 PM with no additional information provided prior to survey exit.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency patient handbook provided to patients at time of admission to service, and interview, the agency failed to provide the correct hours of operation for the state toll-free home health hotline and that its purpose is to receive complaints or questions about local home health agencies. This deficient practice has the potential to affect the ability to file complaints regarding the home health agency for all of the agency patients. Findings included: Missouri Department of Health and Senior Services, Missouri Home Health Hotline operates 365 days per year from 0007:00 AM to 08:00 PM, retrieved 11/23/2021 from https://health.mo.gov/safety/abuse/. Review of the document revised 07/2021 and titled, "Faith Home Healthcare Patient Handbook,” showed the hours of operation for the Missouri Department of Health and Senior Services, Missouri Home Health Hotline as Monday through Friday from 08:00 AM to 04:30 PM with an answering service after 04:30 PM. During a telephone interview on 11/23/2021 at 4:16 PM Record/Patient #5 stated that his/her, “Patient Handbook,” showed the hours of operation for the Missouri Department of Health and Senior Services, Missouri Home Health Hotline as Monday through Friday from 08:00 AM to 04:30 PM with an answering service after 04:30 PM. During a telephone interview on 11/23/2021 at 4:24 PM Record/Patient #6 stated that his/her, “Patient Handbook,” showed the hours of operation for the Missouri Department of Health and Senior Services, Missouri Home Health Hotline as Monday through Friday from 08:00 AM to 04:30 PM with an answering service after 04:30 PM. The findings were reviewed with the administrator on 11/23/2021 at 4:33 PM with no additional information provided prior to survey exit.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to: - Provide an individualized plan of care (POC) that included all the required components (G574); and - Ensure the home health agency (HHA) staff promptly alerted the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggested outcomes are not being achieved and/or that the POC should be altered (G590). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency. .

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 agency policy, and clinical record review, the agency failed to assure that the individualized patient plan of care (POC) included the supplies and equipment required, patient-specific interventions and education, and measurable outcomes and goals in three (Record/Patient #2, #3, and #4) of four full records reviewed. This deficient practice has the potential to affect the coordination of care, outcomes, and goals of all the agency’s patients. Review of undated agency policy titled, “Care Planning,” showed that: - The purpose of the policy was to facilitate appropriate coordination and continuity of care and to promote positive patient outcomes; - Each discipline develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/admission visit; and - The plan is appropriate and realistic based on the patient’s needs and clinical status. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services with a primary diagnosis of type 2 diabetes mellitus (a chronic health condition that affects how your body turns food into energy), and secondary diagnoses of a history of congestive heart failure (a condition in which the heart pumps insufficient blood to meet the body’s metabolic needs), venous thrombosis and embolism (venous thrombosis occurs when a blood clot develops in a blood vessel and reduces the flow of blood through the vessel. Embolism occurs when a piece of a blood clot becomes stuck in a blood vessel and largely obstructs the flow of blood), use of a foley catheter (a tube inserted into the bladder to facilitate drainage of urine), and long-term insulin (a hormone that is essential in turning food into energy) and anticoagulant (blood thinner) use. The patient resided in their own home with a family member. Review of the initial comprehensive nursing assessment visit performed 09/22/21 showed that the patient: - The patient was bedfast and had not been up in his/her wheelchair for almost a year; - Was admitted to services for foley catheter management, fall prevention, pain management, skin care, INR (international normalized ratio)/warfarin (a blood thinner) management, and education related to congestive heart failure and diabetes; - Had an 18 french (diameter of the tube)/10 milliliter (ml) (size of the balloon that holds the catheter in place) foley catheter in place. The patient has an allergy to iodine and needed special catheter insertion kits that did not contain iodine; - Had “not been checking” his/her blood glucose at all; - Performed a blood glucose check during the visit with a result of 216; - Checked their INR during the nursing visit. The patient had their own CoaguChek machine and demonstrated use independently during the nursing visit. The nurse called the INR results to the patient’s primary care physician (PCP); - Nurse unable to assess patient buttocks related to pain. The patient used silver sulfadiazine (an antibiotic ointment applied to the skin to treat wounds and prevent infection) to the buttock twice a day; and - The plan for the next visit was to change foley catheter, INR check, assess glucose log, medication and disease process education, and attempt to assess wounds on buttocks. Review of the plan of care for the dates of 09/22/21 to 11/20/21 showed: - PT/INR obtained per CoaguChek or venipuncture: * The order failed to contain individualized criteria for when to use the CoaguChek and/or when to perform venipuncture; - Complete foley change every 3-4 weeks using sterile technique. The order failed to contain individualized criteria for the range of 3-4 weeks for catheter change; and - Assess buttock for open areas/pressure wounds when able. The POC failed to provide patient specific interventions to assess the bedfast patient’s buttocks RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/06/21 with a primary diagnosis of essential hypertension (high blood pressure), and secondary diagnoses of diabetes, post-traumatic stress disorder, peripheral neuropathy, and depression. The patient resided in his/her own home with daily housekeeping services. Review of the initial nursing assessment performed on 11/06/21 showed that the patient had an ulcer on the second toe of his/her left foot. The patient’s wound is managed through a wound clinic and the patient had an appointment with them on 11/17/21. The assessment failed to contain documentation of the patient’s ability to perform blood sugar checks independently. Review of the POC with date range of 11/06/21 to 01/04/22 showed that: - The POC failed to contain individualized orders for the assessment of the ulcer on the second toe of his/her left foot and the patient’s - The POC failed to contain clarification of what allergies are considered, “other;” - The POC failed to contain all of the supplies required including, but not limited to, a glucometer and wound care supplies; - The POC failed to contain information regarding the wound clinic involved in the care of the patient’s diabetic ulcer; and - The POC failed to contain individualized orders for the assessment of the patient’s blood sugar readings. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to home health services on 10/06/21 with a primary diagnosis of diabetes with non-pressure foot ulcer. Review of the initial nursing assessment performed 10/06/21 showed, in part, that: - The patient’s fasting blood glucose level was 180 and the patient demonstrated proper use of the glucometer. The blood sugar range was 150-180; and - The nurse provided wound care. Review of the POC with date range of 10/06/21 to 12/04/21 showed, in part: - Skilled disciplines to assess, perform, and instruct on moist wound healing for pressure ulcers receiving hydrating treatments and benefits of such treatments. The POC failed to contain: - A listing of the wound care supplies or identify who was providing the supplies for the patient; - Individualized orders to assess patient’s diabetes including, but not limited to, the frequency of blood glucose monitoring; and - Orders for the assessment of the non-pressure diabetic wound. During a telephone interview on 11/24/2021 at 9:26 A.M., licensed practical nurse (LPN) A stated that he/she doesn't monitor the patient's blood sugar or INR. He/tries to provide education. He/she reported to case manager it was difficult to get the patient to follow instructions. The patient is "wasting time" and not willing to be helped. The patient was recertified but not on his/her recommendations. He/she spoke to the director of nursing and case manager and told them the patient wouldn't let him/her do much and wasn't taking education. They said they would monitor. The patient won't let him/her do a skin assessment. He/she has tried to review medications and provide education but the patient is not compliant and he/she was not sure what the patient was being skilled for.

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 policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #2) of four full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the policy titled, "Critical Test Values Reporting", revised 06/01/2008 showed, in part: - All critical test results/values are reported to the physician within one (1) hour of receipt of the results by Agency; - Critical test results are those results/values deemed critical by the laboratory and/or diagnostic center reporting the results/values or the physician ordering the test(s); - The physician is notified of the critical test results, regardless of whether the laboratory and/or diagnostic center notified the physician, and the physician is asked to read back the results; and - The date and time of physician notification and response is documented in the patient’s medical record, along with the following statement: “Critical test results read back by Dr. (name of physician)”. RECORD/PATIENT #2: Review of the start of care visit note dated 09/22/2021 showed, in part: - The patient’s diagnosis included, but not limited to, deep vein thrombosis (DVT, occurs when a blood clot forms in one or more of the deep veins in your body); - The patient will require skilled nursing services that included, but not limited to INR (a blood test to see how well the blood clots)/warfarin (blood thinner) management; and - Patient had coagulation machine and is able to complete independently with nurse observation this date. Review of the plan of care dated 09/22/2021 to 11/20/2021 showed, in part: - The patient’s diagnoses included venous thrombosis (blood clot in deep vein, usually the legs) and embolism (a particle that moves about in blood vessels, either in the veins or arteries such as a blood clot); - Skilled nurse 1wk1 (one visit for one week) effective 09/22/2021, 1wk5 (one visit for five weeks) effective 09/26/2021, there was no order for a SN visit the week of 10/31/2021, 1w1 effective 11/07/2021, 1w1 effective 11/14/2021 and six prn (as needed) visits for skilled disciplines to assess vital signs, pulse oximetry, pain and all body systems, knowledge of disease processes and its associated care and treatment, medication regimen knowledge and signs/symptoms of complications necessitating medical attention each visit; - Skilled nurse may obtain PT (prothrombin time, used to assess and monitor coagulation/INR) per coaguchek or venipuncture; - Care needs included anticoagulation therapy with a goal that patient was to remain within therapeutic range throughout the episode and interventions included to educate patient/caregiver on the importance of taking warfarin as ordered by the physician; and - The plan of care failed to include anticoagulation therapeutic range, who was to report the INR results to the physician and how often. Review of a skilled nursing visit note dated 10/07/2021 showed: - The patient continues to check INR weekly, reports results were 1.1 (INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin); - The patient stated he/she called the primary care physician’s office to report results and states he/she has not received orders; - The patient stated he/she has been taking 7.5 mg (no medication name listed) daily; and - The skilled nurse placed call to the physician’s office to report INR 1.1 with "no changed dosing orders". Review of a physician’s order dated 10/07/2021 showed in part: - PT/INR result was 1.1; - New order for 10 mg daily (no medication name was listed); and - Recheck PT/INR on 10/11/2021. Review of a licensed practical nurse (LPN) visit note dated 10/14/2021 showed: - The patient was on the phone during SN (skilled nurse) visit; - SN was unsure if INR had been checked; - The patient’s family member said the INR was checked but unsure of the exact number; - There was no documentation to show if the PT/INR was rechecked on 10/11/2021 per the physician’s order; and - The documentation failed to show if the LPN asked to review the history of results on the patient’s coagulation machine or ask/offer to check the patient’s INR or whether the LPN conducted a medication review to confirm if the patient actually increased his/her warfarin dose to 10 mg as previously ordered by the physician on 10/7/2021. Review of a registered nurse (RN) visit note dated 10/19/2021 showed in part: - SN visit included INR check (no INR result documented); - Documentation failed to include coagulation results; and - No INR results documented since 10/07/2021 and no follow up from the physician ordering INR recheck on 10/11/2021 (to show if the Warfarin 10 mg was therapeutic). The patient declined a visit on 10/24/2021. There was no physician order for a SN visit the week of 10/31/2021. Review of a LPN visit note dated 11/10/2021 showed in part: - The patient stated he/she held his/her warfarin dose since last week due to INR being 5.3 (INR levels above 4.9 are considered critical values and increase the risk of bleeding); - There was no orders for the patient to hold the warfarin and the documentation failed to show if the patient notified the physician; - Documentation failed to show if the nurse offered or had the patient recheck the INR during the visit; - No documentation of physician being called regarding INR of 5.3 once the nurse become aware of the critical value and no documentation of physician being notified the patient was holding his/her warfarin; and - The agency failed to follow the agency policy to report critical test results to the physician within 1 hour of receipt of the results by agency. Review of a case communication note electronically signed on 11/11/2021 between the LPN and the physician, showed in part: - Patient stated he/she held his/her warfarin dose since last week due to his/her INR being 5.3; - The patient states he/she maintains his/her own INR draws. The agency failed to follow the agency policy to call the physician to report critical test results, document date and time physician notified, document response of physician, and critical test result read back by physician. During an interview on 11/23/2021 at 12:15 PM, the administrator stated the following: - The agency was not responsible for the management of the anticoagulant therapy since the patient was independent with checking INR and reporting results; - The case communication fax regarding the patient reporting INR of 5.3 on 11/10/2021was delivered to the physician on 11/11/2021; and - He/she would expect the nurse to call the physician only if they were managing his/her INR. During an interview on 11/24/2021 at 9:00 AM, the physician’s office manager stated the following: - The physician likes the patient’s INR to be between 2 and 3; - He/she did not see an INR of 5.3 reported; and - He/she did not want to answer any further questions, there may be more information he/she was not aware of and he/she would leave a message for the physician. By the time of the survey exit, the physician had not returned the phone call to the surveyors.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 07/06//2021. During the survey it was determined Faith Home Healthcare is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Faith Home Healthcare was completed on 07/06/2021. The agency had 115 current patients. One condition-level deficiency was identified at an immediate jeopardy (IJ) level as follows: - §484.55 Condition of Participation: Comprehensive Assessment of Patients. An immediate jeopardy (IJ) level for likelihood of harm to one patient (Patient #3) and potential for future harm to other patients was identified during the survey. The findings were confirmed as immediate jeopardy by the Centers for Medicare and Medicaid Services (CMS). On 07/01/2021 at 11:15 AM, the administrator/DON (director of nursing) was informed verbally and in writing via the IJ Template, of the findings identified at an immediate jeopardy level. The agency was afforded the opportunity to remove the IJ and submitted a final removal plan the morning of 07/06/2021. The removal plan failed to remove the immediate jeopardy findings on Patient #3 and was not accepted. At of the time of the survey exit on 07/06/2021, the agency failed to remove the immediate jeopardy potential for current or future patients. §484.55 Condition of Participation: Comprehensive Assessment of Patients remains at the IJ level of non-compliance. Three other condition-level deficiencies were identified during this survey. Condition level deficiencies were identified at: - §484.50 Condition of Participation: Patient Rights; - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality Care; and - §484.105 Condition of Participation: Organization and Administration of Services. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) - see Tag G788. A COVID-19 Focused Infection Control survey was completed on 07/06/2021. One deficiency was identified related to the Infection Control survey.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on policy review, current patient right information, clinical record review, observation, and interview, the agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information. The agency failed to provide in writing, in advance of furnishing care, the following information: - The contact information for the home health agency's current administrator (G414); - The patient has the right to be advised of the names, addresses, and telephone numbers of federal and state-funded entities that serve the area where the patient resides (G446); - The patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge. The agency may only transfer or discharge the patient if: * The agency can no longer meet the patient's needs (G454); * The agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered (G464); * The agency must make efforts to resolve the problem presented by the patient's behavior, the behavior of other persons in the home, or situation (G466); * The agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge (G468); and * The agency must document the problem and efforts made to resolve the problem (G470). The cumulative effect of these deficient practices resulted in the agency's inability to ensure that all patients and/or representatives were informed of their rights and responsibilities.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on policy review, current patient right information, observation, and interview, the agency failed to provide the patient and representative (if any) correct contact information for the current home health agency administrator, to receive complaints in, but not limited to, two (Records/Patients #1 and #3) of three home visits conducted. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all agency patients/representatives. Findings included: Review of the undated agency policy titled, "Patient Bill of Rights and Responsibilities,", showed in part the home health will provide information to the patients/families/caregivers regarding the patient's rights and responsibilities while care and/or services are provided, in accordance with applicable laws, regulations and standards. Review of the patient handbook, revised 02/2021, provided by the agency on 06/28/2021 showed if you need information regarding the services provided by the agency, or if you have a concern, we encourage you to contact the agency and the persons to ask for is the director of nursing (the staff listed was currently the alternate administrator). RECORD/PATIENT #1: During a home visit observation on 06/029/2021 at 9:05 AM, review of the admission packet failed to show the current administrator's name. RN E was listed as the nurse administrator, who was not listed as an employee on the agency's employee list. RECORD/PATIENT #3: During a home visit observation on 06/30/2021 at 8:20 AM, review of the admission packet, failed to show the current administrator's name. The previous administrator was listed, which is currently the alternate administrator. Patient #3 was not provided with the new administrators name or contact information. The record review findings were reviewed with the owner, administrator/director of nursing and the director of clinical services on 06/30/2021 at 4:00 PM, they acknowledged the findings and no further information was presented.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on policy review, current patient right information and interview, the agency failed to update the written notice of patient rights to include that the patient has the right to be advised of the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that serve the area where the patient resides and to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: Review of the undated agency policy titled, "Patient Bill of Rights and Responsibilities,", showed in part the home health will provide information to the patients/families/caregivers regarding the patient's rights and responsibilities while care and/or services are provided, in accordance with applicable laws, regulations and standards. The agency provided an admission packet for review on 06/28/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show accurate information for the Federally-funded and State-funded entities that serve the area where the patient resides. The booklet provided a number for Center for Independent Living in Jefferson City, MO. The surveyor called the number provided on 06/29/2021 at 4:20 PM and was told, that Gladstone was not covered by this phone number. This number was on the wrong side of the state and covered seven counties in Central Missouri. The 800 number listed for the Aging Information Office failed to be the correct number. The surveyor called this number on 6/29/2021 at 4:45 PM and was told it was a resort and hotel. Review of the current patient rights information failed to include the current QIO organization. The agency listed Missouri Foundation for Medical Care as the current QIO organization for their area. The current QIO is Livanta LLC. On 06/30/2021 at 10:27 AM, the findings were reviewed with the agency alternate administrator. The alternate administrator agreed with the need to provide a local numbers for the agency patients and stated this was an easy fix.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to include that the HHA (home health agency) must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission packet for review on 06/28/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show that the HHA (home health agency) must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities During interview on 6/29/2021 at 9:53 AM, the alternate administrator agreed to review the patient handbook in attempt to locate the missing information. On 6/30/2021 at 10:00 AM, the alternate administrator returned the handbook and no additional information was provided.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to provide the written notice of patient rights to meet the requirements to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission packet for review on 06/28/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. On 6/29/2021 this missing information was discussed with the alternate administrator. On 6/30/2021 the alternate administrator had no further information to provide.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to include that if the patient is being considered for a discharge for cause, the agency must make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home or situation. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission packet for review on 06/28/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show that if the patient is being considered for a discharge for cause, the agency must make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home or situation. During interview on 6/29/2021 at 9:53 AM, the alternate administrator agreed to review the patient handbook in attempt to locate the missing information. On 6/30/2021 at 10:00 AM the alternate administrator returned the handbook and no additional information was provided.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to include that if the patient is being considered for a discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission packet for review on 06/28/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show that if the patient is being considered for a discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. During interview on 6/29/2021 at 9:53 AM, the alternate administrator agreed to review the patient handbook in attempt to locate the missing information. On 6/30/2021 at 10:00 AM the alternate administrator returned the handbook and no additional information was provided.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to provide the written notice of patient rights to meet the requirements that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for a discharge for cause. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission packet for review on 06/28/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed that if the patient is considered for a discharge for cause, the agency must document the problem and efforts made to resolve the problem. During interview on 6/29/2021 at 9:53 AM, the alternate administrator agreed to review the patient handbook in attempt to locate the missing information. On 6/30/2021 at 10:00 AM the alternate administrator returned the handbook and no additional information was provided.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health agency failed to ensure the comprehensive assessment met the needs of the patients and resulted in an immediate jeopardy level finding in the following areas: - The clinician must conduct an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or within 48 hours of the patient's return home from a facility, or on the physician-ordered start of care date (G514); - The comprehensive assessment must accurately reflect the patient's status and must include the patient's current health, psychosocial, functional, and cognitive status (G528); and - The comprehensive assessment must include 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 effect, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy (G536). The cumulative effects of these deficient practices caused the likelihood of harm to one patient (Patient #3) and has the likelihood for harm for all the agency's 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, review of agency provided emails, home visit observation, and interviews, the agency failed to ensure an initial assessment visit was provided to patients within 48 hours of referral, or within 48 hours of return to home, or on the physician-ordered start of care date, in two (Records/Patients #3 and #4) of five full records reviewed. This deficient practice has the potential to adversely affect the immediate care needs provided to all the agency's patients. Findings included: Review of the agency's undated policy titled, "Acceptance/Admission of Patients," showed, in part, that a patient who meets the criteria is assessed by the registered nurse/therapist within 48 hours of the received referral unless otherwise dictated by the physician orders. RECORD/PATIENT #3: Review of the referral information form showed: - The patient was referred to the agency when discharged from the skilled nursing facility (SNF) on 06/01/2021; and - The start of care (SOC) visit was scheduled with the RN (registered nurse) on 06/02/2021. Review of the faxed referral information from the SNF dated 06/01/2021 showed an order for physical therapy (PT), occupational therapy (OT), nursing for medication management, and bath aide. Review of the start of care assessment dated 06/08/2021 by the RN, showed the following OASIS (Outcome and Assessment Information Set- a comprehensive assessment designed to collect information related to clinical status, functional status, and service needs) responses: - (M0102) Date of Physician-ordered Start of Care (Resumption of Care) was answered; no specific SOC date ordered by physician; - (M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA was answered; 06/07/2021 (the referral was sent/received on 06/01/2021); - (M1005) Inpatient Discharge Date (most recent) showed 06/01/2021; and - The clinical record failed to include documentation to show why there was a delay in the start of care from 06/02/21 through 06/08/21. Further review of the clinical record from 06/01/2021 through 06/29/2021 failed to show any other documentation of why the start of care was delayed. Review of a communication note dated 06/30/2021 at 3:43 PM showed, an unsigned note by the admitting RN for a delayed start of care due to the patient request 06/01/2021-06/08/2021, patient reports 10/10 back pain, physician notified. This communication note failed to show the date this entry was written for (typically written as a late entry). The patient was interviewed on 06/29/2021 at 4:54 PM per telephone. When questioned about why the start of care was delayed for home health care, he/she stated that he/she could not remember talking to the agency at all before they came to see him/her on 06/08/2021. Per a telephone conversation on 07/06/2021 at 11:11 AM, the patient's daughter stated: - She has not spoken to anyone from the agency ever; and - She did not tell them to delay care. During an interview on 06/29/2021 at 11:15 AM, the alternate administrator stated that a verbal order was received on 06/08/2021 at 1:00 PM to delay the start of care. This was received from the primary care physician's office and given to the SOC RN. There was no order found in the documentation provided by the agency. In reference to the above interview of the alternate administrator, a review of the start of care comprehensive assessment dated 06/08/2021 showed the following: - MD (Medical Doctor) was contacted to approve additional orders not on referral; - Date: 06/08/2021 at 1:00 PM; - Spoke with (receptionist's name) at Dr. (physician's name) office; and - The documentation failed to show what the physician was contacted about. During an interview on 06/30/2021 at 1:57 PM, the patient's primary care physician stated that he/she: - Had no notes in the computer system from 06/01/2021 through 06/07/2021 from the agency regarding this patient; - Does not recall a message or communication from the agency about delaying the patient's SOC; and - Did have documentation that a communication was received from the agency on 06/08/2021 that the patient had been admitted and he/she had an abrasion on the left forearm. During the telephone interview with the patient on 06/29/2021 at 4:54 PM, he/she stated that: - On 06/09/2021 (one day after the patient was admitted to the agency) he/she went to the emergency department (ED) because he/she had a large abscess under his/her left arm and it just kept getting larger. The physician at the ED lanced it, and it drained a lot. He/she was discharged home; and - On 06/11/2021, when he/she went to dialysis, they would not do his/her treatment because there was too much infection in his/her body. They sent him/her to the hospital and he/she was there for 10 days. During an interview conducted on 06/29/2021 at 4:54 PM, the patient stated that the left axilla swelling started while at the SNF (discharge 06/01/2021). Review of the emergency department physician documentation dated 06/11/2021 showed documentation that the arm and axillary area have been causing problems for approximately one week. During an interview on 06/29/2021 at 11:02 AM, the administrator stated that if the start of care had been done in a timely manner, the hospitalization may have been prevented. RECORD/PATIENT #4: Review of the referral information, dated 06/09/2021, showed in part: "Reason for referral - needs home health for recurrent heart failure, and out of control dm (diabetes mellitus) and wounds on butt (buttock) and foot: (Another agency) dismissed due to noncompliance." "Visits allowed: 6" "Start date: 05/21/2021" "End Date: 05/21/2022." Review of the start of care (SOC) assessment dated 06/18/2021 by the RN, showed: - (M0102) Date of Physician-ordered Start of Care (Resumption of Care) was answered; no specific SOC date ordered by physician; and - (M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA was left blank. Review of emails provided by the administrator/director of nursing showed, in part, the following: - Email dated 06/10/2021 at 8:51 AM, from the Regional Marketing Director (in reference to a conversation with the physician's office in attempt to get admitting wound care orders), was sent to the administrator and several other staff. The email states, "I did speak to (referral source) on this one, and she is going to try to get more specific wound care orders, however, she believes the doc wanted us to evaluate the wound and treat as necessary. Most times if wound care comes over from their PCP clinic, this is what is requested. Let me know if we are able to accept and schedule this referral knowing this information as I am unsure if she will have specific wound care orders. I did explain why we like to have this, why it's important, etc. but a lot of PCP's don't know exactly what to do which is why they wanted us to take a look and eval, and recommend treatment." - Email dated 6/17/2021, at 9:26 AM, from the administrator/director of nursing states he/she and the alternate administrator "... talked about this and I called (the previous agency that cared for the patient). I got the scoop on the non-compliance issues. (the previous agency) never treated a buttock wound, so we feel this is new... "We will accept this patient.." The clinical record/additional information failed to show why the initial assessment was delayed until wound care orders were supplied by the physician or more information was received. Review of a verbal order, dated 06/17/2021, showed the start of care date 06/17/2021 (8 days after referral). During an interview on 06/29/2021 at 11:02 AM, the administrator/DON stated: - He/she had communication via fax with the physician's office on 06/09/2021 and 06/10/2021 but no further communication with the physician's office until 06/17/2021. He/she was needing wound care orders and nothing was sent; - On 06/17/2021, he/she called the patient's previous home health agency and found out the toe treatment and why the patient was non-compliant; and - He/she then called the patient's physician on 06/17/2021 to change the evaluation date. The patient did not have any open wounds at the time of the SOC assessment (the documentation failed to show a patient assessment within 48 hours of referral to assess for continued needs).

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interviews, the agency failed to ensure the comprehensive assessment accurately reflected the patient's status and included at a minimum the patient's current health status when the skilled nurse failed to provide a complete assessment of the patient's: Problem #1- Pain and pain management regimen; Problem #2- Skin integrity status; and Problem #3- Full medication reconciliation. These incomplete assessments occurred in, but not limited to, one (Record/Patient #3) of five full records reviewed and resulted in an immediate jeopardy (IJ) level citation. This deficient practice has the potential to adversely affect the care and assessment needs for all the agency's patients. Findings included: Review of the agency's undated policy titled, "Patient Assessment Functions and Qualifications," showed, in part, the following: - The agency provides and modifies care, treatment and/services to meet the patient's needs as identified through assessment, reassessments, and physician orders; - The skilled nurse assesses the physical, cognitive, behavioral, emotional, psychosocial, and rehabilitative needs of the patient, including management of pain; - The nurse monitors the patient's clinical status and coordinates care provision with other members of the team; - The nurse evaluates the patient's response to the plan of care in a timely manner; and - The nurse reassesses the patient to determine the ongoing needs for care, treatment, and /or services. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 06/08/2021 (seven days after the referral was received) after being discharged from the skilled nursing facility (SNF) on 06/01/2021. The patient had a primary diagnosis of COPD (chronic obstructive pulmonary disease-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Secondary diagnoses included, but were not limited to, pneumonia (infection in the lungs), pulmonary hypertension (the pressure in the blood vessels leading from the heart to the lungs is too high), congestive heart failure (the heart does not pump blood effectively), and end stage kidney disease on dialysis (the blood is run through a machine to remove toxins since the kidneys are no longer working effectively). The patient lived in an apartment alone. The daughter filled the medication planner and took care of the medications. The patient had dialysis three times per week. The patient was weak and used a walker and a wheelchair for mobility. Review of the comprehensive assessment dated 06/08/2021 at 11:18 AM to 11:53 AM (35 minutes) completed by RN D showed the following: Problem #1: - M1242 Frequency of pain interfering with patient's activity of movement was rated 4-All of the time; - The pain assessment showed lower back pain rated at "10" (0 being no pain and 10 being the most pain imaginable) with no further assessment of the pain or documentation of the current pain management regimen; and - The narrative note failed to show if the physician was contacted to report the pain at level "10" which was out of the patient's parameter. The plan of care dated 06/08/2021 to 08/06/2021 showed a high pain parameter of 6 out of a 0-10 pain level. Problem #2: - Wound assessments were shown for the left lower arm irritation of the patient's shunt site and left elbow abrasion (scrape) but RN D failed to assess/document the left axilla swelling: - During the interview conducted on 06/29/2021 at 4:54 PM, the patient stated that the left axilla swelling started while he/she was at the SNF (discharge 06/01/2021); and - Review of the emergency department physician documentation dated 06/11/2021 (patient was admitted to the hospital this date related to infected abscess in left axilla) showed; the arm and axillary area have been causing problems for approximately one week (approximately since 06/04/2021). Problem #3: - M2001 Drug Regimen Review showed that a drug regimen review was completed and issues were found; - M2003 Medication Follow-up showed that the physician followed up in response to the identified potential clinically significant medication issues; - M2010 Patient/Caregiver High Risk Drug Education-showed the patient received instruction on special precautions for all high-risk medication (such as hypoglycemic, anticoagulants, etc) and how and when to report problems; - The medication assessment included documentation of major drug interactions and indicated they were faxed to the physician but failed to show patient high risk drug education, listing of high risk drugs, what education was provided, prior medication management, and the physician's response to the fax; - The narrative documentation showed that potential severe medication interactions were provided to the physician and the medications were reconciled; - The documentation failed to show how the medications were reconciled and failed to show if any attempt was made to reconcile the medications with the patient's daughter who filled the medication planner (the medications were with the patient's daughter); * On interview with the patient on 06/30/2021 during the home visit observation, the patient stated that the daughter filled the patient's medication planner and had the medications at her home. The patient gave the surveyor the daughter's number to call to discuss his/her medications and stated that she would be glad to talk to the surveyors but she worked and it is hard to get a hold of her; * Documentation on the start of care comprehensive assessment by RN D failed to show if the patient was taking Coumadin (a high risk drug classified as an anticoagulant-blood thinner) and failed to show a plan for dosing of the Coumadin that should include doing a laboratory blood draw or finger stick in-home lab as ordered by the physician to regulate the medication dose; and - The patient/caregiver information section on the assessment showed there was no patient representative (the patient's daughter was very involved with his/her care and filled his/her medication planner.) During a home visit observation on 06/30/2021 starting at 8:10 AM, the patient was observed sitting in a chair in the living room with oxygen on per nasal cannula. The patient stated he/she had fallen the night before and was having increased pain in the left rib cage area and it hurt when he/she breathed. He/she stated that he/she was sure the ribs were broken because he/she heard a pop. LPN A encouraged the patient to go to the emergency department (ED) but he declined at this time. The patient reported his/her pain level in his/her left side and lower back to be "10" on a 0 to 10 scale. He stated he had just taken pain medication for the pain but it was still bad. Review of the skilled nurse visit note dated 06/30/2021 completed by LPN A showed: - The patient had a pain level of "10" and the physician office was called to report pain and the patient's fall. The staff stated that the patient is on the schedule to have a visit when in the north area next, probably next week; - LPN A noted the patient did not have oxygen on when leaving for dialysis and the patient stated that the portable oxygen was broken. He/she had called the oxygen company two (2) days ago and had not heard from them yet. LPN A stated that he/she would follow up on the next visit to ensure the patient has portable oxygen. Review of the skilled nurse visit note dated 07/02/2021 completed by LPN A showed: - A protime/INR was completed using finger stick and in-home coagulation check machine to give a blood level to dose the Coumadin; - The physician was called with the results; - The patient's daughter who manages his/her medications had still not been contacted; - LPN A was not aware that the daughter did not have the medication, Coumadin/warfarin since the patient's return from the SNF 06/01/2021. LPN A's documentation showed the patient was advised not to take any Coumadin until he/she hears from the physician for dosing and the patient agrees; and - The documentation failed to show if the portable oxygen had been fixed or replaced. Review of the skilled nurse visit note dated 07/05/2021 completed by RN E showed: - The nurse failed to follow-up on the Coumadin dose; - The patient was unsure of when the next protime/INR check was scheduled; - The nurse failed to assess/document if the portable oxygen had been fixed or replaced; and - The nurse documented an incomplete pain assessment as follows: * Pain in left ribs was documented as "5" and described as an ache; * Pain medication was utilized appropriately but there was no documentation of how often it was used; and * Current pain regimen was effective but failed to show what the pain regimen was. The record review findings up to 06/29/2021 and the home visit observations on 06/30/2021 were reviewed with the owner, administrator/director of nursing, and the director of clinical services on 06/30/2021 at 4:00 PM. The owner responded that these were serious concerns and they would start educating their staff.

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, home visit observation, and interviews, the agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment and that the medication profile was updated with medication changes in, three (Records/Patients #3, #1, and #2) of five full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency's undated policy titled, "Medication Management-Patient Information," showed, in part, the following: - The purpose of the policy is to create and maintain an accurate medication history and current medication profile; - During the initial assessment visit, the registered nurse/therapist generates a list of the patient's current medications; - Any questions or concerns about the patient's current medication and herbal remedies are directed to the ordering physician; and - The patient's medications are reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient response to medications are conveyed to the ordering physician. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 06/08/2021. The patient had a primary diagnosis of COPD (chronic obstructive pulmonary disease-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Secondary diagnoses included, but not limited to, pneumonia (infection in the lungs), pulmonary hypertension (the pressure in the blood vessels leading from the heart to the lungs is too high), congestive heart failure (the heart does not pump blood effectively), and end stage kidney disease on dialysis (the blood is run through a machine to remove toxins since the kidneys are no longer working effectively). The patient lived in an apartment alone. The daughter filled the medication planner and took care of the medications. The patient had dialysis three times per week. The patient was weak and used a walker and a wheelchair for mobility. He/she also had a wound in the left axilla that the home health nurse was treating three times per week. The patient was on oxygen therapy continuously. He/she had chronic pain in the lower back that was exacerbated by a fall on 06/28/2021 when he/she also hurt his/her ribs on the left side . During a home visit observation on 06/30/2021 starting at 8:20 AM, the patient was observed sitting in a chair in the living room with oxygen on per nasal cannula. The patient stated that he/she fell last evening and felt his/her ribs pop on the left side and is having increased pain and trouble breathing since then. He/she stated that he/she had taken oxycodone 5mg (narcotic pain medication) two tablets just now for the pain. The patient stated the oxycodone was prescribed when he/she came home from the hospital 06/21/2021. The agency medication profile showed oxycodone 5 mg one tablet every six hours as needed orally. The start date on the agency medication profile was listed as 06/28/2021. The patient was not taking the medication as prescribed on the medication profile. LPN A was questioned regarding the oxygen during the visit, he/she stated that: - "I think the order says 2-3 liters"; and - "Oxygen should be on the medication list". Review of the medication profile failed to show oxygen listed. The patient stated he/she came from the (skilled nursing facility) SNF on 06/01/2021 with oxygen. After the home visit observation was completed, the patient stated as he/she left the home for dialysis, "The portable oxygen is broken." He/she did not have oxygen to take along. He/she stated that the oxygen company was called 2 days ago but he/she has not heard from them. When LPN A heard the patient say he/she did not have portable oxygen to take for his/her appointment, he/she stated that he/she would make sure that was taken care of by the patient's next trip to dialysis. Review of the medication profile failed to show oxygen lested as a medication. The surveyor was unable to review or reconcile the patient's medications with the agency list as the daughter filled the patient's medication planner and had the medications at her home. The patient gave the surveyor the daughter's phone number to call and discuss his/her medications and stated that she would be glad to talk to the surveyors but she worked and it is hard to get a hold of her. Review of the discharge to home medication list from the SNF on 06/01/2021 showed the following medications with known discrepancies: - Coumadin (warfarin) (an oral blood thinning medication that requires laboratory levels to dose the medication) 4.5 mg (milligram) orally at bedtime for atrial fibrillation (fast heart rate); and - Aspirin 81 mg (a low dose mild pain reliever also used to reduce clotting in the blood) one time per day for deep vein thrombosis prevention. Review of the discharge to home medication list from the hospital dated 06/21/2021 showed the following for these two medications: - Coumadin (warfarin) 3mg one tablet orally at bedtime; and - Aspirin 325 mg oral one time per day. Review of the agency's current medication profile printed 06/29/2021 showed the following for these two medications: - Coumadin (warfarin) 1 mg 4.5 mg orally at bedtime dated 06/07/2021; and - Aspirin 81 mg oral one time per day. During an interview on 06/29/2021 at 9:12 PM, the patient's daughter stated: - She was using the most recent medication list she had from the SNF dated 06/01/2021; - She did not have any Coumadin since the patient came home on 06/01/2021 (patient was without this critical medication, except when he/she was hospitalized, the whole time he/she was on service with the agency); and - She thought maybe it was discontinued since the doctor didn't refill it. During another interview on 07/06/2021 at 11:11 AM, the patient's daughter stated that she: - Had not received a medication list from the most recent discharge from the hospital, 06/21/2021; and - Had not heard from the agency and continued to fill the medicine planner from the 06/01/2021 SNF discharge medication list. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2021 with cellulitis of right lower limb (a common and potentially serious bacterial skin infection). During a home visit observation on 06/29/2021 starting at 9:05 AM, the medications were reconciled using a current medication profile supplied by the agency and a list used by the spouse to fill the pill planner which he/she provided to the surveyor. - The agency's current med profile showed: * Acetaminophen-hydrocodone (Norco 5 mg (milligram)- 325 mg) tablet (used to treat moderate to severe pain), one tablet by mouth every four hours as need for pain orally; * Furosemide 80 mg one tablet (used to treat extra fluid in the body) by mouth daily in the morning; * Gabapentin 300 mg (used to treat seizures and nerve pain) one capsule by mouth three times daily in the morning, afternoon and bedtime oral; * Insulin regular (insulin regular human recombinant) (used to lower levels of glucose (sugar) in the blood) 100 units/ml 50 units at dinner injectable; * Oxymetazoline nasal (oxymetazoline) spray 0.05% (used to treat nasal congestion) 2 sprays every 12 hours; * Potassium chloride tablet, extended release 20 mEq (milliequivalent) (a mineral supplement used to treat or prevent low amounts of potassium in the blood) one tablet by mouth daily in the morning oral; * Prednisone tablet 10 mg (used to treat inflammation) one tablet by mouth daily in the morning oral; * Sertraline (Zoloft) 25 mg (used to treat depression) one tablet by mouth daily in the morning oral; * Spironolactone tablet 25 mg (used to treat high blood pressure and can also treat extra fluid in the body) one tablet by mouth daily in the morning; and * Trifluoperazine 2 mg tablet (used to treat behavior problems and anxiety) one tablet by mouth daily as needed for anxiety oral. - Review of the medication bottles and interview with spouse who filled the medication planner showed the following discrepancies: * Acetaminophen-hydrocodone (Norco 5 mg (milligram)-325 mg) tablet, none in the home and the spouse stated he/she knows nothing about this drug; * Furosemide 80 mg, spouse stated he/she is giving one tablet twice a day; * Gabapentin 300 mg, spouse stated the patient only takes it as needed; * Insulin regular (insulin regular human recombinant 100units/ml) 50 units subcutaneous at each meal and bedtime. The spouse stated to ask the patient about the insulin. The patient stated he/she takes 100 units at each meal and at bedtime depending if he/she has eaten; * Oxymetazoline nasal (oxymetazoline) spray 0.05%, spouse stated the patient is taking this only as needed; * Potassium chloride tablet, extended release 20 mEq, spouse stated the patient doesn't take this at all and hasn't for a long time; * Prednisone tablet 10 mg, spouse stated the Dr stopped it because they didn't want him/her getting addicted to it; * Sertraline (Zoloft) 25 mg, spouse does not have this medication and stated he/she knows nothing about it; * Spironolactone tablet 25 mg, spouse stated the patient is taking this twice a day; and * Trifluoperazine 2 mg tablet, spouse stated that he/she was giving this as needed for anxiety and stated he/she doesn't think there is a daily frequency limit. An interview during the home observation visit with the patient's spouse showed they were utilizing the hospital discharge medication list to fill the pill planner and not either of the two lists found in the home supplied by the agency. During an interview on 06/30/2021 at 09:50 AM, the administrator/director of nursing stated that: - Medication reconciliation should be completed by looking at the referral paperwork; - Making notes of meds the patient was discharged with and comparing with the medication bottles in the home; - This would all be reviewed with the person setting up the medications in the pill planner, noting any inconsistencies, and then sent to the physician; and - This should be done every visit. RECORD/PATIENT #2 Review of the clinical record showed the patient was admitted to home health services on 06/05/2021 with a primary diagnosis of multiple rib fractures after a fall. Secondary diagnoses include, but were not limited to, fracture of the right forearm, fractured nose, heart disease, and diabetes mellitus Type II (an endocrine disease where the blood sugars are not controlled and gets too high). He/she lived at the home with the spouse. During a home visit observation on 06/29/2021 at 11:50 AM, the medications were reconciled with the plan of care dated 06/05/2021 and showed the following discrepancies: - Acetaminophen 325 mg two tablets every 6 hours orally. The patient stated that he/she only takes the acetaminophen when it is needed for pain; - Insulin glargine (Lantus) (a long acting insulin taken to control blood sugars) 100 units/ml (milliliter) 18 units at bedtime subcutaneous. The patient stated he/she takes 22 units at bedtime; - A referral medication list from the discharge facility dated 06/04/2021 showed the following medication-metoprolol succinate ER (extended release)(used to treat chest pain (angina), heart failure, and high blood pressure) 12.5 mg (milligram) by mouth in the evening for high blood pressure. Hold medication for systolic blood pressure (the top number) less than 90 or a heart rate less than 50; - The plan of care dated 06/05/2021 listed the medication metoprolol succinate ER 12.5 mg daily but does not instruct to give the medication in the evening; and - The wife showed the surveyor a medication bottle for metoprolol succinate 100 mg tablet take ½ tablet in the morning which failed to be listed on the plan of care; and - Omeprazole 20 mg one capsule orally two times per day before meals which also failed to be listed on the plan of care. On 06/30/2021 at 4:00 PM, the record and visit was reviewed with the administrator/DON and the director of clinical services. They acknowledged the findings.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, observation, and interview, the agency failed to: - Provide each patient an individualized written plan of care (G572); - Promptly alert the relevant physician of changes in the patient's condition that may suggest a need to alter the plan of care (G590); - Provide a visit schedule, including frequency of visits to the patient (G614); - Provide an accurate medication schedule/instructions to the patient (G616); - Provide a copy of written instructions outlining any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services (G618); and - Provide the name and contact information for the clinical manager to the patient (G622). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide each patient with an individualized plan of care that was established by the physician in, but not limited to, two (Record/Patient #3 and #4) of five records reviewed. This deficient practice has the potential to impact the care provided to all agency patients. Finding included: Review of the agency's undated policy titled, "Care Planning," showed, in part, the following: - Purpose: To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes; - Each discipline, develops a plan of care based on the assessment of the patients' needs and clinical status at the time of the initial/admission visit; - The case manager/director of nursing (DON) is responsible for overseeing the care planning process; and - The plan is appropriate and realistic based on the patient's needs and clinical status. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 06/08/2021 with diagnosis of, but not limited to, chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), acute and chronic respiratory failure, pneumonia due to Escherichia coli (bacteria), congestive heart failure, paroxysmal atrial fibrillation (irregular heartbeat), hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), end stage renal disease, dependence of renal dialysis, cognitive communication deficit, and oropharyngeal dysphagia (swallowing problems). Review of the referral information dated 06/01/2021 showed: - The patient was receiving monitoring for anticoagulation medication (medicines that help prevent clots), antianxiety medication, dialysis catheter site monitoring for signs or symptoms of bleeding or infection, as well as, oxygen interventions; and - The patient previously required oxygen at three liters per minute at rest and six liters per minute with activity for chronic respiratory failure. Review of the agency developed plan of care dated 06/08/2021 to 08/06/2021 showed: - The agency failed to include oxygen orders or interventions; - No interventions for diagnosis of congestive heart failure; - No anticoagulation interventions on plan of care; - No orders for protime/international normalized ratio (PT/INR) monitoring with Coumadin (anticoagulation) medication; - "May take orders from the following physicians: all specialty physicians, on-call, ER, acute care hospital and urgent care physicians and team for coordination of patient care," without listing the actual providers that are involved with the patient's care; - The family member's name was not listed on plan of care for contact. (The patients' daughter manages the patient's medications and fills the pill planner); and - "Skilled discipline to assess medication compliance each visit and medication set up every one to two weeks as needed or per patient request." (The patient's daughter does the medication set up for the patient.) During an interview on 06/29/2021 at 9:12 PM, the patient's daughter stated that she was filling the medication boxes using the medication list from the previous rehabilitation facility discharge dated 06/01/2021. RECORD/PATIENT #4: Review of the plan of care (POC) dated 06/18/2021 through 08/16/2021, showed: - The patient was admitted to home health services on 06/18/2021; - Diagnoses included hypertensive heart and chronic kidney disease with heart failure, stage four chronic kidney disease, acute on chronic heart failure and type 2 diabetes mellitus; - Insulin aspart (fast-acting insulin) solution 100 units/ml sliding scale (the progressive increase in pre-meal or nighttime insulin doses) 150-199 6 units, 200-250 8 units, 251-300 10 units, 301-"150" 12 units, 351-400 14 units and call primary care physician, there were no orders for frequency; - Vital sign parameters: *Fasting blood sugar: Low value 60.0 to high value 350.0, random blood sugar: *Low value 70.0 to high value 300.0; *Weight: low value 125.0 to high value 400; - There failed to be interventions on how often the patient weighs and what weight changes were to be reported; - There failed to be instructions on what to do if the patient was outside of these parameters; - Skilled nursing one time a week for one week, one time a week for four weeks and then one time a week for one week to assess vital signs and all body systems, knowledge of disease process(es) and its associated care and treatment, and signs/symptoms necessitation medical attention each visit; and - Skilled disciplines to provide education on self-management of disease process (es) to include, but not limited to: Congestive heart failure and diabetes mellitus. Review of the clinical record showed: - On 06/18/2021, the start of care assessment showed the patient complained of a dull ache in his/her back and knees. The plan of care failed to show pain interventions; - The patient had a weight loss/gain of 10 pounds in the past six months and there failed to be weight monitoring interventions on the plan of care; and - On 06/21/2021, a skilled nursing visit note showed the patient's random blood sugar was 427, there failed to be interventions for random blood sugar checks and the physician was not notified even though the findings were out of the prescribed parameters on the POC. The skilled nurse failed to follow the physician orders. During an interview on 06/29/2021 at 10:25 AM with the administrator/director of nursing and alternate administrator, the alternate administrator stated that: - The weight and vital sign parameters are not individualized unless the physician requests something different; and - If the patient has weight problems they would expect individualized parameters such as a weight loss of two pounds in 24 hours or five pounds in one week; - The electronic medical record software flags all the out of parameter readings when charted and the clinician cannot move on with the charting until they check the box that says the physician has been contacted; - He/she agreed that the instructions were not on the plan of care to call the physician if findings out of parameters; - He/she would call the software company and get that changed; and - Until it was changed, the clinicians can free type the instructions for calling the physician.

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 policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #4: Review of the plan of care (POC) dated 06/18/2021 through 08/16/2021, showed: - The patient was admitted to home health services on 06/18/2021; - Diagnoses included type 2 diabetes mellitus; and -Insulin aspart (fast-acting insulin) solution 100 units/ml (milliliters) sliding scale (the progressive increase in pre-meal or nighttime insulin doses) 150-199 6 units, 200-250 8 units, 251-300 10 units, 301-"150" 12 units, 351-400 14 units and call primary care physician; - The order failed to show a frequency to give the insulin or how often to do blood sugar testing; and - Vital sign parameters show "Random blood sugar: low value 70.0 to high value 300.0" Review of a skilled nursing visit dated 06/21/2021 at 11:21 AM showed the patient's random blood sugar was 427 (out of the prescribed parameter of high value 300.0) and the physician was not notified. During an interview on 06/29/2021 at 10:30 AM, the administrator/director of nursing stated that if a patient's blood sugar was out of range the skilled nurse would get a pop up on the computer screen to fax the physician; - The nurse did not fax/notify the physician of the elevated blood sugar; and - He/she would have expected the physician to be notified.

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 home visit observation and interview, the agency failed to ensure each patient received written information related to visit schedule/instructions in, but not limited to, two (Record #1 and #3) of three applicable home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2021 with cellulitis of right lower limb (a common and potentially serious bacterial skin infection). Review of the plan of care (POC) dated 05/31/2021 through 07/29/2021, showed that the physician ordered skilled nursing (SN) one time a week for nine weeks effective 05/31/2021. The home visit observation with occupational therapy (OT) C on 06/29/2021 starting at 9:05 AM, showed the home folder was reviewed and the agency failed to provide a written frequency of visits for the skilled nurse. RECORD/PATIENT #3 Review of the clinical record showed the patient was admitted to home health services on 06/08/2021 with chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), . Review of the POC dated 06/08/2021 through 08/06/2021 showed that the physician ordered SN one time a week for two weeks effective 06/13/2021, SN one time a week for one week (1w1) effective 07/04/2021, and SN 1w1 effective 07/18/2021. During a home observation visit on 06/30/2021 at 8:20 AM with licensed practical nurse A, the surveyor observed the patient's home chart. The agency failed to provide a written visit schedule and frequency of visits for the skilled nurse. During an interview on 06/30/2021 at 4:00 PM, the owner, administrator/director of nursing, and director of clinical services acknowledged the findings and no further information was provided.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure each patient received updated/current written instructions related to the patient's medication schedule in, but not limited to, one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect all patients admitted to the home care agency. Findings included: Review of the undated agency policy titled, "Medication Management-Patient Information," showed in part: - The home health will create and maintain an accurate medication history and current medication profile while the patient is receiving care, treatment and/or services from agency; - During the initial assessment visit, the registered nurse/therapist generates a list of the patient's current medications, including prescription and over-the-counter medications and herbal remedies; - The information is documented in the agency medication administration record; - The list of current medications is incorporated into the plan of care; - Copies of the plan of care is distributed/conveyed to all healthcare team members involved in the management of the agency patients' medications, care, treatment and/or services, as appropriate; and - The patient/family/caregiver is instructed about the patient's medications verbally and in written format understandable to the patient/family/caregiver. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 06/08/2021. The patient had a primary diagnosis of COPD (chronic obstructive pulmonary disease-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Secondary diagnoses included, but were not limited to, pneumonia (infection in the lungs), pulmonary hypertension (the pressure in the blood vessels leading from the heart to the lungs is too high), congestive heart failure (the heart does not pump blood effectively), and end stage kidney disease on dialysis (the blood is run through a machine to remove toxins since the kidneys are no longer working effectively). The patient lived in an apartment alone. The daughter filled the medication planner and took care of the medications. During a home observation visit on 06/30/2021 at 8:20 AM with the licensed practical nurse A, the home folder/book was reviewed and failed to show a current medication list. The medication list in the home was dated 12/2020. During an interview on 06/29/2021 at 9:12 PM, the patient's daughter stated she was using the most recent medication list she had from the skilled nursing facility (SNF) dated 06/01/2021. On 06/30/2021 at 4:00 PM, the record and visit was reviewed with the owner, administrator/director of nursing and the director of clinical services. They acknowledged the findings. During another interview on 07/06/2021 at 11:11 AM, the patient's daughter stated that she: - Had not received a medication list from the most recent discharge from the hospital, 06/21/2021; and - Had not heard from the agency and continued to fill the medicine planner from the 06/01/2021 SNF discharge medication list.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review, home visit observation and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in, but not limited to, one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: RECORD/PATIENT #3 Review of a Resumption of Care assessment (assessment completed after an inpatient stay) dated 06/22/2021 at 1:18 PM showed: - The patient had an incision under the left underarm from an abscess removal; - The skilled nurse assessed the wound; - Removed the dressing and cleansed the incision with wound cleanser; - Packed the incision with Hydorfera Blue (moist wound dressing); and - Covered the dressing with gauze and secured with tape. During a home observation visit on 06/30/2021 at 8:20 AM with licensed practical nurse A, the surveyor observed the patient's home chart. The agency failed to provide written wound care instructions. On 06/30/2021 at 4:00 PM, the record and visit was reviewed with the owner, administrator/director of nursing and the director of clinical services. They acknowledged the findings.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation, and interview, the agency failed to provide in writing the name and contact information of the clinical manager in, but not limited to, two (Patient # 1 and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: During a home observation visit on 06/29/2021 starting at 9:05 AM with OT (Occupational therapist) C, the surveyor observed the patient's home folder. The folder in the home had a sticker on the front of it with the contact phone number of the agency and listed the clinical manager as the alternate administrator (not current clinical manager). The agency failed to provide in writing the name of the current clinical manager. RECORD/PATIENT #3: During a home observation visit on 06/08/2021 starting at 8:20 AM with licensed practical nurse A, the surveyor observed the patient's home folder. The agency failed to provide in writing the name of the current clinical manager. On 06/30/2021 at 4:00 PM, the record and visit was reviewed with the owner, administrator/director of nursing and the director of clinical services. They acknowledged the findings.

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 standards of practice for infection control, home visit observation, and interview, the agency staff failed to follow accepted standards of practice for one (Record/Patient #3) of three patients observed during home visits. This deficient practice has the potential to adversely affect the health and safety of all the patients receiving care from the agency. Findings included: Review of McGoldrick, M. (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc. showed the following procedure for hand hygiene and bag technique: - Perform hand hygiene; - Remove the supplies from the bag and place them on a clean, dry surface, or a surface barrier as needed; - Do not reenter the bag with gloves on. Remove the gloves if worn, perform hand hygiene, and then reenter the bag; - Clean the equipment and supplies that had direct patient or environmental contact as needed; and - Remove personal protective equipment if worn, and perform hand hygiene. RECORD/PATIENT #3: During the home visit observation on 06/30/2021 beginning at 8:20 AM, Licensed Practical Nurse (LPN) A was observed performing wound care to the left axilla (armpit). The nurse failed to maintain infection control standards when the following occurred: - The left axilla wound was previously cultured and was positive for methicillin-resistant staphylococcus aureus (MRSA); - Patient had a piece of tape that remained in place after the remainder of the old dressing had fallen off and the nurse attempted to remove the tape without wearing gloves; - The nurse cleansed the scissors with a sanitizer wipe and then proceeded to cut the Hydrofera Blue (foam dressing) without changing gloves; - The nurse removed her left glove and entered her bag for a head lamp without sanitizing her hands; - After cleaning the wound, the nurse turned on her head lamp with the same gloves that were used when cleaning the wound; and - The nurse used a bottle of solution to moisten the Hydrofera Blue before packing into the wound. The solution bottle was labeled, sterile water for inhalation with one time use only. The patient was provided the bottle of solution at discharge from the hospital on 06/21/2021. During interview on 06/30/2021 at 8:53 AM, LPN A stated, "I probably should have just taken both gloves off," after he/she had only removed the left glove and attempted to use sanitizer gel on only his/her left hand prior to reapplying a new glove. When asked about the policy for MRSA precautions, the nurse reported they were the same as standard precautions. LPN A also stated he/she was not aware that large bottles were not to be reused and would order some syringes of normal saline. During an interview on 06/30/2021 at 4:00 PM, the owner, administrator/director of nursing, and director of clinical services acknowledged the findings and 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 clinical record review and interview, the agency failed to ensure that skilled nursing followed the physician's orders as indicated on the patient's individualized plan of care related to skilled nursing visit frequency in two (Record/Patient #1 and #5) of five records reviewed. This deficient practice has the potential to adversely affect the care of all the patients served by the agency. Findings Included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2021 with cellulitis of right lower limb (a common and potentially serious bacterial skin infection). Review of the Plan of care dated 04/01/2021 to 05/30/21 showed skilled nursing (SN) two times a week for one week, effective 04/04/2021. Review of the skilled nursing visit notes showed only one skilled nursing visit the week of 04/04/2021. The agency failed to notify the primary care physician of the missed visit. During an interview 06/30/2021 at 9:50 AM the administrator/director of nursing stated there was no communication with the physician regarding the missed visit and stated "this surprises me." RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 04/12/2021 with acute respiratory failure. Review of the plan of care dated 04/12/2021 to 06/10/2021 showed SN one time a week for six weeks, effective 04/11/2021. Review of the skilled nursing visit notes showed the agency failed to document a SN visit the week of 04/25/2021 and failed to notify the primary care physician of the missed visit. During an interview on 06/30/2021 at 4:00 PM, the owner, administrator/director of nursing, and director of clinical services acknowledged the findings and no further information was provided.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with four Conditions of Participation: Patient rights; Comprehensive assessment of patients; Care planning, coordination of services and quality of care; and Organization and administration of services, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/06/2023.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on policy review, job description review, record review, observation, and interviews, the agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to show adequate governing body, administrative, and clinical manager oversight to patients resulting in four condition of participation citations. The following standard level deficiencies were cited under this condition of participation: - Governing body-responsible for assuming full legal authority and responsibility for the agency's overall management and operation (G942); - Administrator-must be responsible for all day-to-day operations of the agency (G948); and - Clinical Manager-Oversite must include coordinating patient care, coordinating referrals, and assuring that patient needs are continually assessed (G958). The cumulative effect of these systemic practices resulted in the agency's inability to ensure the patient's care needs would be met.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on policy review, job description review, record review, observation, and interviews, the agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to show adequate governing body, administrative, and clinical manager oversight to patients resulting in four condition of participation citations. The following standard level deficiencies were cited under this condition of participation: - Governing body-responsible for assuming full legal authority and responsibility for the agency's overall management and operation (G942); - Administrator-must be responsible for all day-to-day operations of the agency (G948); and - Clinical Manager-Oversite must include coordinating patient care, coordinating referrals, and assuring that patient needs are continually assessed (G958). The cumulative effect of these systemic practices resulted in the agency's inability to ensure the patient's care needs would be met. the board of directors is the governing body for the agency and as such possesses ultimate responsibility and legal authority (as indicated by state license and or charter, articles of incorporation, constitution, bylaws or similar documents) for managing the organization and for the quality of care, treatment and services provided. During the unannounced recertification survey, the surveyors entered the agency's suite inside the business location on 06/28/2021 at 11:30 AM. The following information was gathered by observation and interview: - The glass door on the suite showed the name of the agency "Faith Home Healthcare" but failed to show business hours or a telephone number to reach staff; - There was a piece of paper taped to the door that showed Faith Hospice with hours and a telephone number; - The surveyors were greeted by a staff member seated at a desk directly opposite the door. He/she identified his/herself by name and title of hospice chaplain; - The hospice administrator then came out of the second office on the far left of the room and greeted the surveyors with name and title; - He/she then attempted to reach the home health administrator by a telephone call and could not reach him/her; - At 11:40 AM, the hospice administrator then attempted to text the home health administrator with no reply; - The director of clinical services was then called at 11:49 AM and would be at the office around 12:15 PM; - The surveyors were directed by the hospice administrator to wait in the first office on the left (there were two offices off the main room). He/she stated that the office was the hospice case manager's office but was used by the home health administrator/director of nursing (DON) when he/she was in this office; - During the wait for the administrator/DON, observation of the office showed papers on the desk related to hospice paperwork, a dry erase board calendar that showed IDT (interdisciplinary team meetings) and non-home health patient names, an employee telephone list on the wall showed no home health employees listed, a Faith Home Health and Hospice wall map showed "Hospice Service Area" with a map of counties, admission packets on the desk were for Faith Hospice, supplies stored on the floor of the room in open boxes were adult diapers and incontinent pads, and there were cabinets along the wall with patient use gloves stored on top and other miscellaneous patient supplies; and - The hospice administrator stated that it was a very small office and they did not have much room to store the hospice supplies. During an interview at 11:52 AM, the hospice administrator stated that: - He/she had not seen the home health administrator/DON at all last week but he/she was in and out of the office on two days and the home health administrator/DON could have come in when he/she was out; - All calls go the Kansas City, Kansas office first and they get transferred calls in this office for hospice; - Sometimes he/she does get calls for home health but they are very few; - No home health nurses or therapists come to this office; - There is a room in Kansas City, Kansas office just for home health supplies; and - He/she was not sure if there were any home health patient records kept in this office. At 12:13 PM, the director of clinical services arrived at the office. He/she stated that: - The home health administrator/DON was at a doctor's appointment and would arrive soon; - He/she worked for the corporate level and mainly worked at the Kansas City, Kansas office; - He/she oversees all the home health agencies; - He/she named the current DON of the Missouri office and the alternate administrator/DON who was also the Kansas home health agency administrator/DON; - There were three registered nurses (RN) and two licensed practical nurses (LPN) working for the Missouri home health agency; and - He/she stated that most home health staff go to the Kansas office to get supplies if they cannot wait for supplies to be sent to the patient's or staff's home from Medline (a supply company). At 12:10 PM, the alternate administrator/DON arrived at the office. The following was the sequence of events regarding obtaining the admission folder: - On 06/28/2021 at 12:23 PM, the patient admission packet was requested for review and none were found in the office; - At 12:29 PM, the director of clinical services made a phone call to a staff member (unknown) and asked if he/she knew if there were any home health admission folders still over here (Missouri office); - At 12:31 PM, the director of clinical services reported to the surveyors that the administrator/DON was called to reroute his/her trip to the Missouri agency and go back to the Kansas agency to pick up a Missouri folder; and - At 1:26 PM, the home health administrator/DON and the home health agency owner arrived. The administrator/DON brought the Missouri patient admission packet and stated that he/she worked out of the Missouri office almost every day (refuted by the hospice administrator's earlier statement). During an interview on 06/28/2021 at 1:12 PM, the director of clinical services stated that: - The Kansas intake coordinators make the admission packets at the Kansas agency as that was the "main hub"; - When the Missouri office is open, either the hospice or home health administrator/DON is always at the office and they coordinate with each other so one of them is there if one of them has to be out; and - There are three intake staff and since the Missouri office is so small, the Missouri staff member works in the Kansas agency. During an interview on 06/28/2021 at 3:50 PM, the administrator/DON stated that: - He/she was the director of nursing for the Missouri office and had been employed there about three months; - The director of clinical services was the administrator; - The director of clinical services stated that he/she was not the administrator and that the DON was also the administrator; - The administrator/DON stated, "I thought I was the director of nursing;" - The director of clinical services replied, "You are both, it was in your job description;" and - The administrator/DON then stated, "I guess I am both." On 06/29/2021 at 10:55 AM, the director of clinical services stated that: - He/she was the home health director for day to day operations; - The intake coordinator was full time at the MO office until March 2021 and then moved to the KS office; - For people to know the Gladstone office is there they would call the phone number which is to the KS office and the Kansas office would direct the calls to the Gladstone office; and - The agency was working on getting someone to work on marketing to show Gladstone exists. When preparing for this survey, the surveyor became concerned when he/she realized the telephone number for the agency was a Kansas area code. On 06/22/2021 at 3:00 PM a telephone call was made to the listed number. The number was answered and the person stated he/she was in the Kansas agency office and could not connect the surveyor to the Gladstone, Missouri agency office. He/she then connected the surveyor to another person who only gave his/her first name. He/she stated that he/she sometimes worked at the Gladstone agency and sometimes in Kansas agency office. When asked if the surveyor could talk to a case manager at the Gladstone office he/she stated that they were currently not in the office. He/she would not connect the surveyor to the Gladstone, Missouri agency office. During an interview on 06/30/2021 at 10:30 AM, the alternate administrator/DON stated that: - The owner had explained some things about this agency earlier today and he/she would try to explain again for this surveyor; - The two agencies (Kansas and Missouri) have two tax identification numbers; - There is one training hub at the Kansas office for both agencies: - This is a common operating practice for corporations; - Each agency pays its employees out of its own bank account; and - Because the agency's administrator/DON was so new (about 3 months since hired), the day to day administration and financials go through the corporation.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on current survey findings, policy review, administrator job description review, and interviews, it cannot be assured the administrator or alternate administrator has effectively assumed responsibility for the overall administration, supervisory functions, and overall operations of the home health agency. The agency failed to show the administrator or alternate administrator were responsible for all day-to-day operations of the agency. This deficient practice has the potential to affect all the patients receiving services from the agency. Findings included: This deficient practice led to the failure of the agency to comply with four Conditions of Participation: - §484.50 Condition of Participation: Patient Rights; - §484.55 Condition of Participation: Comprehensive Assessment of Patients; - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality Care; and - §484.105 Condition of Participation: Organization and Administration of Services. Review of the agency's undated policy titled, "Organization and Structure," showed, in part, the administrator, relying upon accountability from the director of patient care services, clinical supervisors, billing department, and the office manager is responsible for the financial aspects and overall function of the organization. Review of the agency's undated policy titled, "Agency's Administrative and Supervisory Responsibilities," showed, in part, the board of directors shall appoint an administrator who is responsible for the daily operation of the organization and is available on the premises or by phone at all times during operating hours. Review of the administrator job description showed, in part, the following, the administrator: - Plans, coordinates, directs and controls the operations of the agency; - Ensures that qualified personnel are hired and that such personnel receive adequate in services and evaluations; and - Participates in the agency's information management and performance improvement programs. During the unannounced recertification survey, the surveyors entered the agency's suite inside the business location on 06/28/2021 at 11:30 AM. The following information was gathered by observation: - The surveyors were greeted by a staff member seated at a desk directly opposite the door. He/she identified his/herself by name and title of hospice chaplain; - The hospice administrator then came out of the second office on the far left of the room and greeted the surveyors by providing his/her name and title; - He/she then attempted to reach the home health administrator by a telephone call and could not reach him/her; - At 11:40 AM, the hospice administrator then attempted to text the home health administrator with no reply; and - The director of clinical services was then called at 11:49 AM and would be at the office around 12:15 PM. During an interview on 06/28/2021 at 11:52 AM, the hospice administrator stated that: - He/she had not seen the home health administrator/director of nursing (DON) at all last week but he/she was in and out of the office on two days and the home health administrator/DON could have come in when he/she was out; - All calls go to the Kansas City, Kansas office first and they get transferred calls in the Missouri office for hospice; - Sometimes he/she does get calls for home health but they are very few; and - No home health nurses or therapists come to this office. At 12:13 PM, the director of clinical services arrived at the office. He/she stated that the home health administrator/DON was at a doctor's appointment and would arrive soon. At 12:19 PM, the alternate administrator/DON arrived at the office. The following was the sequence of events regarding obtaining the admission folder: - On 06/28/2021 at 12:23 PM, the patient admission packet was requested for review and none were found in the office; - At 12:29 PM, the director of clinical services made a phone call to a staff member (unknown) and asked if he/she knew if there were any home health admission folders still over here (Missouri office); - At 12:31 PM, the director of clinical services reported to the surveyors that the administrator/DON was called to reroute his/her trip to the Missouri agency and go back to the Kansas agency to pick up a Missouri folder; and - At 1:26 PM, the home health administrator/DON and the home health agency owner arrived. The administrator/DON brought the Missouri patient admission packet and stated that he/she worked out of the Missouri office almost every day (refuted by the hospice administrator's earlier statement). During an interview on 06/28/2021 at 1:12 PM, the director of clinical services stated that: - The Kansas agency intake coordinators made the admission packets at the Kansas office as that was the "main hub"; and - When the Missouri agency is open, either the hospice or home health administrator/DON is always at the office and they coordinate with each other so one of them is there if one of them has to be out (an earlier interview with the hospice administrator refutes this statement). During an interview on 06/28/2021 at 3:50 PM, the administrator/DON stated that: - He/she was the director of nursing for the Missouri office and had been employed there about three months; - The director of clinical services was the administrator; - The director of clinical services stated that he/she was not the administrator and that the DON was also the administrator; - The administrator/DON stated, "I thought I was the director of nursing;" - The director of clinical services replied, "You are both, it was in your job description;" and - The administrator/DON then stated, "I guess I am both;" and - This interview showed the administrator/DON just learned this date he/she was the administrator and had the responsibility for the day-to-day operations of the agency. On 06/30/2021 at 9:32 AM, the administrator stated that he/she reported to the alternate administrator and his/her duties were to: - Help with schedules and was not sure why he/she had to do schedules; - Put ICD-10 diagnoses codes in for the start of care and resumption of care OASIS (Outcome and Assessment Information Set). (The coding company sent the information and he/she inputs the information); - Look at the OASIS data and scrub the assessments (puts the assessments through a software system to check for errors) and makes sure they are complete; - Check the plans of care for the correct start dates, end dates, and interventions; - Verify all visits after they were locked for payroll; - Make sure the visits are completed and locked; - Do case conferences with the staff; - He/she has not been involved with the QAPI (Quality Assessment and Performance Improvement) committee since he/she started at the agency; and - These duties fail to show responsibility for the day-to-day operations of the agency.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on current survey findings, policy review, clinical manager job description review, home visit observation, and interviews, it cannot be assured the clinical manager has effectively assumed responsibility for oversight of all patient care services, coordinating patient care, and coordinating referrals of the home health agency. The agency failed to show the clinical manager was responsible for assuring that the patient needs were continually assessed and the development, implementation, and updates of the individualized plan of care were completed. The agency failed to provide the clinical manager's name and contact information so the patient/caregiver would know who to contact for concerns about their treatment and services on two (Record/Patients #1 and #3) out of three home visit observations conducted. (The agency's designated title for the clinical manager was director of nursing (DON).) This deficient practice has the potential to affect all the patients receiving services from the agency. Findings included: This deficient practice led to the failure of the agency to comply with four Conditions of Participation: - §484.50 Condition of Participation: Patient Rights; - §484.55 Condition of Participation: Comprehensive Assessment of Patients; - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality Care; and - §484.105 Condition of Participation: Organization and Administration of Services. Review of the agency's undated policy titled, "Agency's Administrative and Supervisory Responsibilities," showed, in part, the following: - The board of directors shall designate a full-time director of nursing services to supervise the agency's performance in providing home health services; - The services will be: * In accordance with agency's policies and procedures; * The orders of the physician responsible for the care of the patient; * Under a written plan of treatment established by such physician; and - Is available on the premises or by phone at all times during operating hours. Review of the clinical manager job description showed, in part, the following, the clinical manager: - Coordinates all patients' services by reviewing plans of treatment, assuring case conferences are conducted, reviewing clinical and progress notes, periodic patient evaluations, and determining frequency and/or staffing patterns; - Aids in the agency goal of retaining quality personnel by appropriately hiring, orientating, training, evaluating and disciplining personnel within established policy; - Ensures personnel are scheduled to ensure proper coverage within authorized staffing levels; - Ensures orientation and ongoing training programs are developed and provided for agency personnel; - Conducts performance evaluations in a timely, measurable and objective manner. Communicates this information to the administrator; - Maintains a working knowledge of current Medicare, Medicaid, and third party payer requirements for home care reimbursement; - Communicates and coordinates with physician's offices, payers, patient/families, outpatient services and inpatient coordinator, regarding the care and status of the patient; and - Participates in the agency's information management and performance improvement programs. RECORD/PATIENT #1: During a home observation visit on 06/29/2021 starting at 9:05 AM with OT (Occupational therapist) C, the surveyor observed the patient's home folder. The folder in the home had a sticker on the front of it with the contact phone number of the agency and listed the Missouri office nurse administrator as a previous administrator/DON that is no longer employed with the agency (not the current clinical manager). The agency failed to provide in writing the name of the current clinical manager. RECORD/PATIENT #3: During a home observation visit on 06/08/2021 starting at 8:20 AM with licensed practical nurse A, the surveyor observed the patient's home folder. The agency failed to provide in writing the name of the current clinical manager. On 06/30/2021 at 9:32 AM, the administrator/director of nursing stated that he/she reported to the alternate administrator and his/her duties as director of nursing included: - Help with schedules and was not sure why he/she had to do schedules; - Put ICD-10 diagnoses codes in for the start of care and resumption of care OASIS (Outcome and Assessment Information Set). (The coding company sent the information and he/she inputs the information); - Look at the OASIS data and scrub the assessments (puts the assessments through a software system to check for errors) and makes sure they are complete; - Check the plans of care for the correct start dates, end dates, and interventions; - Verify all visits after they were locked for payroll; - Make sure the visits are completed and locked; - Do case conferences with the staff; - He/she has not been involved with the QAPI (Quality Assessment and Performance Improvement) committee since he/she started at the agency; and - These duties failed to show oversight of all patient care services and personnel.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Section 192.2495 RSMo, 192.2495.6 RSMo, and 192.2495.7 RSMo, personnel file review, and interview, the agency failed to request and obtain results of findings of the Family Care Safety Registry (FCSR) prior to patient contact for four employee (Employee #1, #2, #3 and, #4) of five personnel files. This deficient practice has the potential to affect the safety of all patients served by the agency. Findings included: Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: "A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020." Review of Section 192.2495.7, RSMo (effective August 28, 2018): "Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183." EMPLOYEE #1 (E1): Review of E1's personnel file showed: - Date of hire 03/15/2021; - Date of first patient contact 03/25/2021; and - The agency failed to request and obtain results of findings of the FCSR prior to patient contact. EMPLOYEE #2 (E2): Review of E2's personnel file showed: - Date of hire 04/26/2021; - Date of first patient contact 05/03/2021; and - The agency failed to request and obtain results of findings of the FCSR prior to patient contact. EMPLOYEE #3 (E3): - Date of hire 04/19/2021; - Date of first patient contact 04/26/2021; and - The agency failed to request and obtain results of findings of the FCSR prior to patient contact. EMPLOYEE #4 (E4): - Date of hire 03/12/2021; - Date of first patient contact 03/24/2021; and - The agency failed to request and obtain results of findings of the FCSR prior to patient contact. During an interview on 06/30/2021 at 10:50 AM, the president stated the home health agency does not go through the FCSR to check each employee and they would start doing this.

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 agency policy review, clinical record review, and interview, the agency failed to ensure a transfer summary was sent within two business days of a planned transfer to the receiving facility in two (Record/Patient #3 and #6) of two discharge records reviewed. This deficient practice has the potential to affect all discharged or transferred patients served by the agency. Findings included: Review of the undated agency's policy titled, "Discharge, Transfer, and Referral of Patients," showed in part: - Any discharge, transfer or referral of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and/or receiving facility and in such a way as to prevent harm to the patient; - External transfer: Example hospitalization; *Agency is notified of hospitalization and will place the patient on hold and then follow up with external facility to collect admission data such as admit date and diagnosis; *Clinical staff completes the transfer summary form and transfer oasis; and *Agency faxes medication list and transfer summary form to primary care physician and external facility within 48 hours of notification. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was hospitalized from 06/11/2021 to 06/21/2021; and - On 06/16/2021 at 8:12 AM, the transfer summary was submitted to the primary care provider via fax. During an interview with the administrator/director of nursing on 06/29/2021 at 10:50 am, stated the transfer summary was sent to the primary care provider and he/she was unable to find documentation of the transfer being sent to the receiving facility. RECORD/PATIENT #6: Review of the Outcome and Assessment Information Set (OASIS) showed: - Date assessment completed 06/02/202; and - The patient was transferred to an inpatient facility and patient not discharged from agency. Review of a transfer form to the primary care physician dated 06/10/2021 (8 days after the patient's transfer) showed: - Verbal order received 06/10/2021 (8 days after the patient's transfer); and - Discharge date: 06/02/2021: Discharge/transfer to skilled nursing facility. During an interview on 06/29/2021 at 12:35 PM, the administrator/director of nursing stated that: - The patient was transferred to the rehabilitation facility and a transfer form was faxed to the physician on 06/10/2021; - They sent the face sheet, medication list and notes to the rehabilitation facility prior to the rehabilitation facility accepting the patient; - The transfer summary was sent to the physician not the rehabilitation facility; - The rehabilitation facility accepted the patient on 06/02/2021; - The patient was actually transferred on 06/10/2021; and - No further information was provided.

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 policy review and clinical record review, the agency failed to ensure all documented entries included appropriate authentication that included the correct date and time the plan of care was completed in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all of the patients served by the agency. Findings included: Review of the agency policy undated and titled, "Patient Assessment Functions and Qualifications," showed: - All physician orders on plan of care or any other addendum, verbal order must be documented in the patients chart at the time of receiving them; and - All documentation must be completed within 24-48 hours to include all patient pertinent information. RECORD/PATIENT #3: - On 06/29/2021, a copy of the start of care OASIS (Outcome and Assessment Information Set- a comprehensive assessment designed to collect information related to clinical status, functional status, and service needs) was obtained by administrator/director of nursing (DON) and showed clinical record item (M0104) Date of Referral: Indicate the date the written or verbal referral for initiation or resumption of care was received by the home health agency (HHA) and was answered with the date of 06/01/2021; - On 07/01/2021, a second copy of the start of care OASIS was obtained and showed clinical record item (M0104) Date of Referral: Indicate the date the written or verbal referral for initiation or resumption of care was received by the HHA being answered with the date of 06/07/2021 (the referral date was dated six days after the first OASIS copy referral date and there was no communication note or addendum provided to explain why the date was changed on M0104); - There was no documentation to show explanation for the late entry; - The copy of the start of care OASIS that was received on 07/01/2021 had the same timestamp as the copy obtained on 06/29/2021, there was no communication note or addendum provided to explain why the referral date was changed on the OASIS question (MO104); - On 06/29/2021, a copy of the updated plan of care following the resumption of care on 06/22/2021 was obtained from the administrator/DON (director of nursing) and vital sign parameters for reporting pain was low value 0 to high value 6; - On 07/01/2021, a second copy of the updated plan of care following the resumption of care on 06/22/2021 showed the parameter for reporting pain was low value of 0 to high value of 9; - There was no physician order for the change in pain parameters; - RN (registered nurse) D faxed a case communication note dated 06/30/2021 at 3:43 PM to the primary care physician that showed "delayed start of care due to patient request, 06/01/21-06/08/21. Patient reports 10/10 back pain, physician notified." The case communication note includes a back date effective 06/08/2021; - OT (occupational therapist) C, entered and faxed a case communication note dated 06/30/2021 at 3:46 PM to the primary care provider that showed the "patient reports 9/10 pain back and left elbow. He is not taking pain meds as prescribed because they cause constipation and he does not have any stool softeners. His daughter is picking up stool softeners this evening. Lowest pain is 6/10 with pain management due." OT C backdated the effective date to 06/10/2021; and - Documentation failed to explain details of the late entry, when the symptoms occurred, if the symptoms were reported when discovered, and who RN D and OT C spoke with regarding symptoms.