Every finding on record at First Care Home Health Inc

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey conducted at your facility on 08/16/2022 and finalized on 08/19/2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The agency was found to be in substantial compliance with the requirements for Emergency Preparedness. No further action necessary.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted at your agency from August 16, 2022 through August 19, 2022, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census on the first day of the survey was 31 patients. The patient sample was seven patients. Three home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure clinicians followed physician orders in the plan of care for 2 of 7 patients (Patient 4, and 5). Findings include: 1) Patient 4 was admitted on 7/19/2022 with diagnoses including diabetes mellitus II. The plan of care dated 07/19/2022, documented a physician ordered weekly skilled nursing visits with the nurse to weigh the patient weekly. On 7/26/2022 and 8/4/2022, documented skilled nursing visits conducted lacked documented evidence of patient weights for those visits. On 8/19/2022 at 1:05 PM, the Administrator confirmed the findings. Procedure 6 of the Plan of Care and Physician Orders policy revealed care and services provided would be provided according to physician orders. 2) Patient 5 was admitted on 7/10/2022, with diagnoses including diabetes mellitus II and unspecified open wound of left buttock. On 8/3/2022, the FNP ordered a 2-view x-ray of the sacrum and coccyx. On 8/18/2022, the clinical record lacked documented evidence the x-ray was completed. On 8/18/2022 at 1:10 PM, the agency contact person confirmed the radiology company representative indicated the x-ray was not done.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure services were conducted only as ordered by a physician for 2 of 7 patients (Patient 1 and 4). Findings include: 1) Patient 1 was admitted on 4/8/2022, with stage II pressure ulcer of the right buttocks. On 4/8/2022, the plan of care documented a physician ordered twice weekly home health aide visits. The clinical record lacked documented evidence the order was changed, discontinued, or otherwise modified. For the week of 4/24/2022 to 4/30/2022, the clinical record had documented evidence of home health aide visits on 4/25/2022, 4/27/2022 and 4/29/2022. On 8/19/2022 in the afternoon, the Administrator confirmed the finding. Procedure 1 of the Plan of Care and Physician Orders policy revealed the plan of care was established in consultation with the physician, agency staff, the patient, and members of the patient's family. The plan of care included frequency of visits and duration. 2) Patient 4 was admitted on 7/19/2022, with diabetes mellitus II. On 8/3/2022, the clinical record documented a social worker conducted a social services visit. On 8/19/2022, the clinical record lacked documented evidence a physician ordered a social services evaluation. On 8/19/2022 at 1:05 PM, the Administrator confirmed the finding. Procedure 7 of the Plan of Care and Physician Orders policy revealed treatments were administered only as ordered by a 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 observation, interview and record review, the agency failed to ensure a clinician notified a physician of a change in condition for 1 of 7 patients (Patient 6). Findings include: Patient 6 was admitted on 4/8/2022, with lumbar region spondylolysis. The clinician who conducted the start of care assessment documented negative genitourinary findings. On 6/3/2022, the agency recertified Patient 6 from 6/7/2022 through 8/5/2022. The clinician who conducted the recertification assessment documented negative genitourinary findings. On 8/5/2022, the agency recertified Patient 6 from 8/6/2022 through 10/4/2022. The Administrator conducted the recertification assessment and documented negative genitourinary findings. On 8/5/2022, the plan of care documented a physician ordered weekly physical therapy visits. On 8/17/2022, a home visit was conducted with a physical therapy assistant. During the visit, the chief caregiver indicated Patient 6 had multiple episodes of urinary urgency resulting in incontinence many times throughout the day. These episodes had been occurring for some time. Patient 6 was observed with a wet spot in the perianal area of the clothing from behind as ambulation therapy was conducted. The caregiver mentioned the underclothes were changed multiple times daily due to the incontinence. The clinical record lacked documented evidence of any diagnosis, medication or plan of care intervention addressing the incontinence. On 8/19/2022 in the afternoon, the clinical record lacked documented evidence of any of the above references to the patient's incontinence and that the case manager or the agency office was notified. The clinical record lacked documented evidence a physician was notified. The Administrator confirmed the findings.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient received an x-ray as ordered for 1 of 7 patients (Patient 5). Findings include: Patient 5 was admitted on 7/10/2022, with diabetes mellitus II and unspecified open wound of left buttocks. On 8/3/2022, the Family Nurse Practitioner (FNP) ordered a 2-view x-ray of the sacrum and coccyx. On 8/18/2022, the clinical record lacked documented evidence the x-ray was completed. On 8/18/2022 at 1:10 PM, the agency confirmed the radiology company representative indicated the x-ray was not done and no indication in the chart what happened. The clinical record lacked documented evidence the agency followed up with radiology and checked periodically to monitor when the x-ray would be completed or if there was a delay.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a home health aide correctly documented tasks performed during a home health aide visit for 1 of 7 patients (Patient 1). Findings include: Patient 1 was admitted on 4/8/2022, with stage II pressure ulcer of the right buttocks. On 6/2/2022, the agency recertified Patient 1 from 6/7/2022 through 8/5/2022. On 6/7/2022, the plan of care documented a physician ordered twice weekly home health aide visits. On 6/21/2022, 6/24/2022 and 6/27/2022, home health aides documented the patient refused all ordered tasks on the home health aide visit forms. On 8/19/2022 in the afternoon, the Administrator confirmed the findings and indicated the home health aides conducted all the visits and performed the ordered tasks, which were incorrectly documented. The Documentation Guidelines for EMR (electronic medical records) revealed entries must be accurate, relevant, timely and complete.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency's registered nurse failed to ensure a home health aide followed the plan of care for 1 of 7 patients (Patient 5). Findings include: Patient 5 was admitted on 7/10/2022, with diabetes mellitus II. On 7/10/2022, the plan of care documented a physician ordered home health aide visits twice weekly. On 7/10/2022, a registered nurse documented the home health aide plan of care for the subsequent visits with 10 tasks listed. On 7/14/2022, 7/16/2022 and 7/17/2022, a home health aide documented completion of 12-14 tasks on each visit. On 7/20/2022, a registered nurse documented a home health aide supervisory visit. The nurse documented everything as satisfactory. There was no provision to check on the list which indicated the home health aide followed the plan of care. On 7/22/2022 and 7/26/2022, a home health aide documented completion of 13 tasks on each visit. On 8/19/2022 at 11:15 AM, the Administrator confirmed the findings. The Home Health Aide Supervision policy revealed home health aides were closely supervised to ensure their competence in providing care.

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 record review, interview and policy review, the agency failed to ensure clinical records were authenticated for 4 of 7 patients (Patient 3, 4, 5 and 6). Findings include: 1) Patient 3 was admitted on 11/22/2021, with hypothyroidism. On 7/18/2022, the agency recertified Patient 3 from 7/20/2022 to 9/17/2022. By 8/19/2022, the agency failed to ensure a clinician authenticated the recertification assessment in the clinical record. On 7/21/2022, the agency transferred Patient 3 to acute care. On 8/8/2022, the agency conducted a resumption of care assessment. By 8/19/2022, the agency failed to ensure a clinician authenticated the resumption of care assessment in the clinical record. 2) Patient 4 was admitted on 7/19/2022, with diabetes mellitus II and conducted a start of care assessment. By 8/19/2022, the agency failed to ensure a clinician authenticated the start of care assessment in the clinical record. 3) Patient 5 was admitted on 7/10/2022, with diabetes mellitus II. On 7/27/2022, the agency transferred Patient 5 to acute care. On 8/1/2022, the agency conducted a resumption of care assessment. By 8/19/2022, the agency failed to ensure a clinician authenticated the resumption of care assessment in the clinical record. On 8/19/2022 in the afternoon, the Administrator confirmed the above findings. 4) Patient 6 was admitted on 4/8/2022, with lumbar region spondylolysis. On 8/5/2022, the agency recertified Patient 6 from 8/6/2022 through 10/4/2022. On 8/17/2022, the physical therapist authenticated the recertification assessment during the inspection, instead of within 5 days of initiation. The Documentation Guidelines for EMR (electronic medical records) revealed authentication included the identity and professional discipline of the author, the date, and the time signed.