Every finding on record at Franklin County Public Health Services Chha

The following statement of deficiencies represents the results of a re-certification survey of Franklin County Public Health Services, Certified Home Health Agency (CHHA), conducted October 7, 2024 through October 10, 2024. A standard re-certification survey was initiated on October 07, 2024. Deficient practices were identified within Level 1 standards in 484.50 Patient's Rights resulting in a partial extended survey. The survey consisted of a review of ten clinical records including three discharge records, six personnel records for professional personnel and four observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for the past twelve months, agency's Admission Packet, the Emergency Preparedness Plan and the Complaint Log. The census at the time of the survey was seventy-eight. Pre-survey activities consisted of review on October 1, 2024 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 07/2023 through 06/2024, the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2023 through 12/31/2023 and the agency's compliance with report submissions for the 2022 statistical report. The agency's Director of Public Health, Director of Patient Services and Supervising Community Health Nurse were interviewed. Findings were reviewed at the exit conference on October 10, 2024. The following deficiencies are identified as a result of the survey: Federal: G0372, G0434, G0440, G0514, G0520, G0528, G0546, G0574, G0590, and G0798. State: J0404, J1108, J1136, J1156, J1276, J1424, R1034 and W0407.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2023 through 12/31/2023 and staff interview the agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary. Failure to encode and electronically transmit each complete OASIS assessment, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary has the potential for incorrect and incomplete reporting data. On 10/04/2024 the surveyors reviewed the Certification and Survey Provider Enhanced Reports (CASPER), The "Home Health Agency Error Summary Report by Agency" for the report period 01/01/2023 - 12/31/2023. The report contains a warning code -3330 "Record Submitted Late": The submission date is more than thirty days after M0090 "Date Assessment Completed" on this new record. The CASPER Report states 6 (0.63%) out of 950 assessments processed were submitted more than thirty days after M0090. The agency lacks documented evidence the agency submitted required documents timely for 6 out of 950, or for 0.63% of submissions. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure that patients are informed before care is initiated of the frequency of services to be provided in one out of ten records reviewed (Patient # 7). Failure to ensure that patients are informed before care is initiated of the frequency of services to be provided has the potential to result in the patient's inability to exercise their rights. Patient # 7 (start of care 11/15/2017) has diagnoses of Multiple Sclerosis and Cramp and Spasm. The record contains the agency's Home Health Consents and Agreements document dated 02/01/2022 that informs the patient they will be receiving Physical Therapy and Home Health Aide services. The form documents the frequency of Physical Therapy services only. The record lacks documented evidence the patient was informed of the frequency of home health aide services. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that patients are informed of their financial liability in one out of ten records reviewed (Patient # 7). Failure to ensure that patients are informed their financial liability has the potential to result in the patient's inability to exercise their rights. Patient # 7 (start of care 11/15/2017) has diagnoses of Multiple Sclerosis and Cramp and Spasm. The record contains the agency's Home Health Consents and Agreements document dated 02/01/2022 that informs the patient they will be receiving Physical Therapy and Home Health Aide services. The form includes financial liability for the Physical Therapy services only. The record lacks documented evidence the patient was informed of financial liability for home health aide services. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in three out of ten records (Patient # 1, 3 and 5) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patient's return home or on the physician ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Patient # 1 (start of care 07/26/2023) has diagnoses of Ventricular Fibrillation and Diabetes Mellitus due to Underlying Condition without Complications. The record contains an initial assessment conducted on 07/26/2023 stating the initial community referral was received on 07/19/2023 without a physician's specified start of care date. The record also contains a physician's order (dated 07/25/2023) for a start of care date of 07/26/2023. The record is lacking documentation of any communication between the physician and the agency between 07/19/2023 and 07/25/2023. The initial assessment was conducted on 07/26/2023, seven days after the agency received the initial referral. Patient # 3 (start of care 09/11/2024) has diagnoses of Fracture of Unspecified Part of Right Clavicle and Other Fracture of Shaft of Right Ulna. The record contains a referral faxed to the agency on 09/06/2024 without a specified physician's ordered start of care date and a physician's order dated 09/10/2024 for a start of care date of 09/11/2024. The record lacks documented evidence of any communication between the agency and the physician between 09/06/2024 and 09/10/2024. The initial assessment was conducted on 09/11/2024, five days after the agency received the initial referral. Patient # 5 (start of care 09/20/2024) has diagnoses of Unspecified Open Wound of Left Forearm and Hydronephrosis with Ureteral Stricture. The record contains a referral dated 09/16/2024 with a physician expected start of care date of within "48 hours (Urgent)". The initial assessment conducted on 09/20/2024 states the referral was received on 09/17/2024. The initial assessment was conducted three days after the agency received the referral. The findings were confirmed on 10/08/2024 at 3:15 PM with the Director of Patient Services and Supervising Community Health Nurse and on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in two out of ten records (Patient # 5 and 9) the comprehensive assessment was completed in a timely manner, but no later than 5 calendar days after the start of care. Failure to complete the comprehensive assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Patient # 5 (start of care 09/20/2024) has diagnoses of Unspecified Open Wound of Left Forearm and Hydronephrosis with Ureteral Stricture. The record contains an initial comprehensive assessment conducted on 09/20/2024 and signed as complete on 09/30/2024. The comprehensive assessment was completed 11 days after the start of care. Patient # 9 (start of care 01/19/2024, discharged 02/29/2024) has diagnoses of Encounter for Adjustment and Management of Ventricular Assist Device (VAD) and Sepsis due to Methicillin Susceptible Staphylococcus Aureus. The record contains an initial comprehensive assessment conducted on 01/19/2024 and signed as complete on 01/28/2024. The initial comprehensive assessment was completed 10 days after the start of care. Also, the record contains a resumption of care assessment completed 02/09/2024 and signed as complete on 02/14/2024. The assessment was completed 6 days after the resumption of care. The findings were confirmed on 10/09/2024 at 3:45 PM and 10/10/2024 at 11:30 AM with the Director of Patient Services; no additional evidence was provided.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure in one out of ten records (Patient # 6) the comprehensive assessment included a complete picture of the patient's status to assist the agency in developing the patient's plan of care. Failure to ensure comprehensive assessments include a complete picture of the patient's status to assist the agency in developing the patient's plan of care has the potential to result in unmet patient needs and negative patient outcomes. Patient # 6 (start of care 04/23/2024) has diagnoses of Type 2 Diabetes Mellitus and Developmental Disorder of Scholastic Skills. The comprehensive assessment conducted on 08/30/2024 states: "Patient will check blood sugar twice a day (BID) and as needed (PRN)". The assessment lacks documentation of any durable medical equipment or device the patient would be using the check the blood sugar. The assessment lacked a complete picture of the patient's status to assist the agency in developing the patient's plan of care. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one out of ten records (Patient # 7) the comprehensive assessment was conducted the last 5 days of every 60 days beginning with the start-of-care date, unless there is a beneficiary elected transfer, significant change in condition; or discharge and return to the same HHA during the 60-day episode. Failure to conduct the comprehensive assessment the last 5 days of every 60 days beginning with the start-of-care date, unless there is a beneficiary elected transfer, significant change in condition; or discharge and return to the same HHA during the 60-day episode has the potential to result in unmet patient needs and negative patient outcomes. Patient # 7 (start of care 11/15/2017) has diagnoses of Multiple Sclerosis and Cramp and Spasm. The record contains a recertification assessment conducted on 06/06/2024 and physician's recertification plan of care for the certification period 06/11/2024 through 08/09/2024. The comprehensive assessment was completed 6 days prior to the end of the 60-day episode. Also, the record contains comprehensive assessments completed on 06/06/2024 and 08/08/2024. The assessment completed on 08/08/2024 was completed 62 days from the previous assessment without documented evidence of a beneficiary elected transfer, significant change in condition or discharge and return to the same home health agency. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in one of ten patient records reviewed (Patient # 10). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Patient # 10 (start of care 07/14/2023, discharged 08/02/2023) has diagnoses of Fracture of Unspecified Part of Neck of Left Femur and Unspecified Bacterial Pneumonia. The physician's POC for certification period 07/14/2023 through 09/11/2023 contains an order for: Acetaminophen-hydrocodone (Norco 5 milligrams (mg)-325 mg) tablet 325 mg-5mg 1 tablet every day (QD) at noon and may take another throughout the day if needed for pain 6-7 on pain scale of 0-10, maximum daily dosage (MDD) of acetaminophen 3000 mg in combination with other meds with acetaminophen, oral, pain. The order is incomplete as it is lacking a time interval between the first dose and the potential second dose. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of ten patient records (Patient # 5) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Patient # 5 (start of care 09/20/2024) has diagnoses of Unspecified Open Wound of Left Forearm and Hydronephrosis with Ureteral Stricture. The record contains an initial skilled nurse assessment stating the patient reports having left arm wound pain that is at a level of 6/10 (out of a 1-10 pain scale), is dull and occurs during wound care. The physician's POC for certification period 09/20/2024 through 11/18/2024 does not contain any pain control measures ordered. The record lacks documented evidence the physician was notified of the level of the patients pain and the lack of pain control measures ordered. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of patients receiving paraprofessional aide services and staff interview the agency failed to ensure in one of one record reviewed (Patient # 1) the aide Plan of Care (POC) was complete to meet the individualized needs of the patient. Failure to ensure the development of a comprehensive aide POC that reflects the patient's needs has the potential to result in inappropriate care, unmet patient needs and possible negative outcomes. Patient # 1 (start of care 07/26/2023) has diagnoses of Ventricular Fibrillation and Diabetes due to Underlying Conditions Without Complications. The record contains an aide POC dated 09/17/2024 that states the patient has allergies of plastic tape and a physician's POC for certification period 09/18/2024 through 11/16/2024 that states the patient has allergies of penicillin, Advil, naproxen sodium, nitrofurantoin macrocrystalline and plastic tape. The aide POC was not revised to include all allergies noted on the physician's POC. The finding was confirmed on 10/09/2024 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

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 clinical record review and staff interview, evidence is lacking in one out of six therapy only records (Patient # 5), that an updated, maintained, and accurate comprehensive medication review was performed by the Registered Nurse (RN) at the start of care. Failure to update and maintain an accurate medication review has the potential to result in the patient experiencing adverse medication effects, drug reactions and/or interactions and the inaccurate administration of physician ordered medications. Finding: Patient # 5 (start of care 07/22/2022) has diagnosis of Other Fracture of Right Lower Leg and Chronic Obstructive Pulmonary Disease. The record contains an initial assessment (dated 07/25/2022) completed by the physical therapist. The record lacks documented evidence that the RN performed a medication review. The finding was confirmed on 07/09/2022 at 1:50 PM with the Supervising Public Health Nurse; no additional evidence was provided.

The following statement of deficiencies represents the results of a standard re-certification survey of Franklin County Public Health Services, Certified Home Health Agency conducted on November 1, 2021 through November November 4, 2021. The survey consisted of a review of ten clinical records, including three discharge records, six personnel records, two observational home visits and two telephonic home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, the agency's Admission packet, the Emergency Preparedness Plan, and Complaint Log. A focused COVID-19 survey was conducted in conjunction with the recertification survey. Pre-survey activities consisted of review on October 26 2021 of the Agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period August, 2020 through July, 2021, and the agency's compliance with report submissions for the 2019 statistical report and the Emergency Drill conducted June 11 through June 13, 2019. The agency's Director of Patient Services and staff were interviewed. The following deficiencies are identified as a result of the survey: Federal: G 0572 Plan of Care; G 0574 Plan of Care must Include the Following; G 0590 Promptly Alert Relevant Physician of Changes; G 1010 Contents of Clinical Record; State: J 0212 Patient Rights; J 0228 Patient Rights; J 1108 Governing Authority; J 1328 Contracts; and J 1440 Personnel.

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 clinical record review and staff interview the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in one of ten patient records (Patient # 5). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Findings: Patient # 5 (start of care 05/01/2021) has diagnoses of Hypertensive Heart Disease and Chronic Diastolic (Congestive) Heart Failure . The POC for certification period 08/29/2021 through 10/27/2021 contains an order for: - Telehealth Monitoring of: Weight, Blood Pressure (BP), Heart Rate (HR), and O2 (Oxygen) Sat (Saturation) Levels, QD (Everyday) except weekends and holidays, RN (Registered Nurse) to teach patient/caregiver to write results in a log daily and when to report to PCP (Primary Care Physician) if VS (Vital Signs) are out of parameters. RN to report if VS are out of parameters to PCP. The record lacks any documented evidence Telehealth monitoring was completed on 09/17 and 10/21/2021 The findings were confirmed on 11/03/2021 at 10:55 AM with the Director of Patient Services; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in four of ten patient records (Patient # 2, 4, 5 and 10). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 2 (start of care 10/22/2021) has diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Left Artificial Knee Joint. The POC for certification period 10/22/2021 through 12/20/2021 contains orders for: - Levothyroxine tablet 50 mcg (micrograms) (0.05 mg (milligrams) QD (every day) at 0600 oral THYROID. The order is incompletes as it lacks instruction to take medication 30 minutes to one hour before meal. Patient # 4 (start of care 06/09/2020) has diagnoses of Essential (Primary) Hypertension and Major Depressive Disorder. The POC for certification period 10/02/2021 through 11/30/2021 contains an order for: - Levothyroxine capsule 125 mcg (micrograms) (0.125 mg (milligrams) TAKE 1 QD TAB (tablet) oral THYROID. The order is incompletes as it lacks instruction to take medication 30 minutes to one hour before meal. Patient # 5 (start of care 05/01/2021) has diagnoses of Hypertensive Heart Disease and Chronic Diastolic (Congestive) Heart Disease. The POC for certification period 10/28/2021 through 12/26/2021 contains orders for: - Fluticasone-Salmeterol (fluticasone-salmeterol CFC) 115 mcg-21 mcg /inh (inhalation) Inhalation COPD (Chronic Obstructive Pulmonary Disease). The order is incompletes as it fails to specify right, left or both nares. - Omeprazole (oxygen) 2 L (liter) 2 L via Nasal cannula continuously supplement. The order requires clarification as it appears to link two different medications. Patient # 10 (start of care 10/08/2020 and discharge 11/04/2020) has diagnoses of Sepsis due to Streptococcus, Group B and Enterocolitis due to Clostridium Difficile, Not Specified as Recurrent. The POC for certification period 10/08/2020 through 12/06/2020 contains an order for: - Rivaroxaban tablet, 20 mg WITH DINNER, QD, Oral, Reason: Anticoagulation Therapy - Warfarin tablet, 5 mg, QD, Oral, Reason: Anticoagulation Therapy The POC is incomplete as it lacks Bleeding Precautions as a Safety Measure. The findings were confirmed on 11/03/2021 at 10:55 AM, 1:25 PM, 1:35 PM, 3:25 PM and 11/04/2021 at 9:50 AM with the Director of Patient Services; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of ten patient records (Patient # 5) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Findings: Patient # 5 (start of care 05/01/2021) has diagnoses of Hypertensive Heart Disease and Chronic Diastolic (Congestive) Heart Failure . The POC for certification period 08/29/2021 through 10/27/2021 contains an order for: - Monitoring - Signs/Symptoms-Physical - When to notify providers, at each visit, VITAL SIGN PARAMETERS TO BE REPORTED TO MD (Medical Doctor) IF: BP (Blood Pressure) (Greater than) 160/90, HR (Heart Rate) 110, O2 SAT 101. Patient does not check blood sugars and is monitored by MD at office. patient to weigh self daily, RN (Registered Nurse) to assess weight log at each visit, RN to teach patient to weigh self daily, patient to report to MD/RN if daily weight gain is >2 lbs. (Pounds). The record lacks documented evidence the physician was notified of a patient weight gain of 3 lbs. on 09/08 and a weight gain of 3 lbs. 09/12/2021. Additionally, the record lacked documented evidence the physician was notified the patient had a HR of 49 and 50 on 10/26/2021. . The findings were confirmed on 11/03/2021 at 10:55 AM with the Director of Patient Services; no additional evidence was provided.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in one of ten records (Patient # 9) that professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care. Failure to maintain an accurate, current and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Finding: Patient # 9 (start of care 08/13/2021 and discharged 10/11/2021) has diagnoses of Parkinson's Disease and Type II Diabetes Mellitus with Diabetic Polyneuropathy. The physician Plan of Care (POC) for the certification period 08/13/2021 through 10/11/2021 states the patient takes Atorvastatin tablet 10 mg (milligram) at HS (Hours of Sleep), QD (everyday), Oral. The POC lists the following as patient allergies; Codeine, Guaifenesin, Sulfa Zonisamide, Statins, Zithromax and Metformin. The record lacks documented evidence of clarification of Atorvastatin and the patients allergy to Statins. The finding was confirmed on 11/03/2021 at 1:25 PM with the Director of Patient Services; no additional evidence was provided.