Every finding on record at Gifted Healthcare Inc

A recertification survey was conducted on 10/10/2022. The census was 24 Licensed and Certified patients. An exit conference was conducted on 10/13/2022. The agency was in compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 10/10/2022. The census was 24 Licensed and Certified patients. An exit conference was conducted on 10/13/2022. Abbreviations: DON - Director of Nursing OASIS -Outcome Assessment Improvement Set RN – Registered Nurse

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure the comprehensive assessment accurately reflected the patient's weight and medications 1 (Patient 1) of 1 patient records reviewed with a primary diagnosis of Congestive[Heart Failure. The outcomes included confusion about a baseline weight which could impact the ability to monitor the patient's fluid status, and also included an inaccurate medication list on the comprehensive assessment, the plan of care, and the medication list. Record review of Patient 1’s clinical record revealed a comprehensive assessment completed by the Director of Nurses on 08/05/2022 at the start of care. The assessment documented the primary diagnosis was Chronic Diastolic (Congestive) Heart Failure. The assessment documented a weight of 194 pounds on page 3 and 245 pounds on page 6. The assessment documented pitting edema of the right and left lower extremities. The assessment contained medications Ergocalciferol (Vitamin D) and Ferrous Sulphate (Iron). The assessment failed to include a measurement of abdominal girth. Review of Patient 1’s clinical record revealed a Plan of Care for the certification period 08/05/2022 to 10/03/2022 with a start of care date of 08/05/2022, and a Medication Profile dated 10/03/2022 for the certification period 10/04/2022 to 12/02/2022 which both documented the medications Ergocalciferol and Ferrous Sulphate. The record contained documentation of a transfer to in-patient care on 08/24/2022 (during the third week of care) for an unknown reason. During a home visit to Patient 1’s residence on 10/11/22, the surveyor observed the patient used a wheelchair to move around the home. The surveyor observed both the patient’s feet and ankles were edematous (swollen). The surveyor reviewed the medications provided by the patient and observed the Ergocalciferol and Ferrous Sulphate were not present. In an interview with the Patient on 10/11/22 at 3 PM, the surveyor reviewed the medications and asked about the Ergocalciferol and Ferrous Sulphate. Patient 1 stated they had not taken those medications for at least 6 months. Patient 1 stated they managed their own medications and set up a pill box weekly and self-administered medications. Patient 1 stated the nurse did not weigh the patient during the home visits. The surveyor asked about the edema observed in the patient’s feet and ankles. The Patient stated they had problems with their feet and legs swelling. The surveyor reviewed the home folder left by the agency in the Patient’s home and noted a vital signs flow sheet was present. There were no weights or other fluid status measurements on the vital signs sheet. An interview was conducted with the Director of Nurses on 10/13/2022 at 11:30 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 1. The surveyor asked why the comprehensive assessment contained two different weights. The Director of Nurses stated the lower one was correct because the patient had just come from a skilled rehabilitation facility and the patient was “on Lasix to get the fluid off while in the skilled rehab.” The surveyor asked if the nurse weighed the patient. The nurse stated she did not weigh the patient. The surveyor asked how the nurse was monitoring the Patient’s primary diagnosis of heart failure. The Director of Nurses stated she “should be measuring her abdomen” since she could not weigh the patient safely. The surveyor asked if the nurse was doing those measurements. The Director of Nurses stated she was not measuring the abdomen. The surveyor asked why the medications listed on the assessment contained medications the Patient stated she was not taking (Ergocalciferol and Ferrous Sulphate). The Director of Nurses stated the electronic medical record software automatically put in medications and weights from previous assessments. The surveyor asked if the plan of care and the medication list also included the incorrect medications was because of the errors on the comprehensive assessment. The Director of Nurses stated: “Yes.” The surveyor asked about the outcome of the assessment being incorrect. The Director of Nurses stated: “I will fix it. I just missed it.” Agency policy and procedure titled: “Patient Assessment Guidelines PE.2” dated 03/01/15 read in part: “Purpose- To provide accurate and consistent patient assessments. Policy Agency will utilize and adhere to a defined comprehensive assessment in order to identify the patient’s needs for home care …The Comprehensive Assessment and OASIS data collection will be completed by a Registered Nurse when nursing care is being provided…Pertinent data/information will be communicated within the inter-disciplinary team, as well as to the patient’s physician…” Agency policy and procedure titled: “Medical Record Content IM.8” dated 10/01/11 read in part: Policy – Agency will initiate and maintain an individual and accurate medical record for each patient receiving care … Each medical record will contain the following: …Height and weight as appropriate to patient care … Patient’s needs information, as documented in both initial assessments and ongoing assessments, which reflects: … An updated medication profile to include medication …”

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 observation, record review, and interview the agency failed to ensure 3 (Patient 1, 2, and 3) of 3 patients’ chosen for home visits had a review of all medications currently being used. The outcome was the medication lists were inaccurate and the agency was unable 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. Record review of Patient 1’s clinical record revealed a medication profile for the certification period 10/04/2022 to 12/02/2022 and a comprehensive assessment completed by the Director of Nurses on 08/05/2022 at the start of care. Both documents contained medications Ergocalciferol (Vitamin D)and Ferrous Sulphate (Iron). Record review revealed a referral from the skilled rehabilitation provider with a history and physical which listed current medications dated 08/04/2022 which included a list of current medications for Patient 1. The list of medications did not include Ergocalciferol and Ferrous Sulphate. During a home visit to Patient 1’s residence on 10/11/22 the surveyor observed and reviewed the medication containers provided by Patient 1 and observed the Ergocalciferol and Ferrous Sulphate were not present in the patient’s medications. In an interview with Patient 1 on 10/11/22 at 3 PM, the surveyor reviewed the medications and asked about the Ergocalciferol and Ferrous Sulphate. Patient 1 stated they had not taken those medications for at least 6 months. Patient 1 stated they managed their own medications and set up a pill box weekly and self-administered medications. The surveyor reviewed the home folder left by the agency in the client’s home and observed a list of medication which included Ergocalciferol, and Ferrous Sulphate was present in the home folder. An interview was conducted with the Director of Nurses on 10/13/2022 at 11:30 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 1. The surveyor asked why the medications listed on the assessment and medication list contained medications Patient 1 stated she was not taking (Ergocalciferol and Ferrous Sulphate), and that the referring skilled rehabilitation list of current medications did not list. The Director of Nurses stated the electronic medical record software automatically put in medications and weights from previous assessments. The Director of Nurses stated the patient had been in and out of the hospital frequently, and the incorrect medications was because it wasn’t updated during the initial comprehensive assessment. The surveyor asked about the outcome of the assessment being incorrect. The Director of Nurses stated that it should be updated and “I will fix it. I just missed it.” Record review of Patient 2’s clinical record revealed a medication profile for the certification period 09/26/2022 to 11/24/2022 which contained medications Topiramate (anti-convulsant) and Ubrogepant (for migraines). A plan of care completed by the Director of Nurses and dated 09/26/2022 included medications Topiramate and Ubrogepant. During a home visit to Patient 2’s residence on 10/11/22 the surveyor observed and reviewed the medication containers provided by Patient 2 and observed the Topiramate and Ubrogepant were not present in the patient’s medications. In an interview with Patient 2 on 10/11/22 at 3:30 PM, the surveyor reviewed the medications and asked about the Topiramate and Ubrogepant. Patient 2 stated those were old medications they had previously taken for migraine headaches, and they had not taken them for at least 6 months since the injectable Emgality was started in April 2022. Patient 1 stated they managed their own medications and set up a pill box weekly and self-administered medications. The surveyor reviewed the home folder left by the agency in the client’s home and observed a list of medication which included Topiramate and Ubrogepant was present in the home folder. An interview was conducted with the Director of Nurses on 10/13/2022 at 11:40 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 2. The surveyor asked why the medications listed on the medication list and plan of care contained medications Patient 2 stated she was not taking (Topiramate and Ubrogepant). The Director of Nurses stated the electronic medical record software automatically put in medications from previous assessments. The Director of Nurses stated the patient had been discharged from the hospital in September 2022 after a fall in the home and a fractured her back, the client took a lot of medications for migraines, and the incorrect medications were because the medication list wasn’t updated during the initial comprehensive assessment. The surveyor asked about the outcome of the medication list being incorrect. The Director of Nurses stated that it should be updated and that she would correct the error. The Director of Nurses stated the patient managed her own medications so there wasn’t an adverse outcome. Record review of Patient 3’s clinical record revealed a start of care date of 06/15/2019 and a Plan of Care and Medication Profile for the certification 09/27/2022 to 11/25/2022 which failed to contain 7 supplements (Reishi Mushroom, Estradius, Magnesium, Co Q 10, Vitamin C, Zinc, and a Multivitamin with iron) which Patient 3 stated she took daily. During a home visit to Patient 3’s residence on 10/11/22, the surveyor reviewed the medication profile and plan of care copies in the home folder. The surveyor observed these documents were signed by RN A, dated 09/24/2022, and did not contain the 7 supplements (Reishi Mushroom, Estradius, Magnesium, Co Q 10, Vitamin C, Zinc, and a Multivitamin with iron). In an interview with Patient 3 on 10/11/22 at 1:30 PM, the surveyor asked about the supplements Patient 3 was taking. Patient 3 stated she took Reishi Mushroom, Estradius, Magnesium, Co Q 10, Vitamin C, Zinc, and a Multivitamin with iron) daily as recommended by her cardiologist. Patient 3 credited these supplements for her long life. Patient 3 stated she had taken these supplements for years. Patient 1 stated they managed their own medications, and a Family Member took care of getting the medication and supplements from the pharmacy. An interview was conducted with the Director of Nurses on 10/13/2022 at 11:50 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 3. The surveyor asked why the medications listed on the medication list and plan of care did not contain a complete list that included the supplements taken by Patient 3. The Director of Nurses stated she had documented the supplements during one of her visits in the past and she should have put this on the medication list. The Director of Nurses didn’t know which visit note had the list but said she would look for it. The Director of Nurses stated the electronic medical record software automatically put in medications from the previous assessments and it should have been updated during the assessment. The Director of Nurses stated she would speak with the RN doing the visits. The surveyor asked about the outcome of the medication list being incomplete. The Director of Nurses stated that it should be updated and that she would contact the RN to update the medication list. The surveyor asked if the medication list being incomplete was the reason the plan of care was also incomplete. The Director of Nurses stated: “Yes.” No additional information was provided by the end of the survey to correct the deficient practice findings. Agency policy titled “Medication List and Monitoring TX.16” dated 050110 read in part: “Policy – An Agency RN will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all Agency staff involved in the patient’s care. A medication profile/list will be maintained on all patients… Procedure – Agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient… The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Agency nursing staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen… “ Agency policy titled “Medical Record Content IM.8” dated 100111 read in part: Policy – Agency will initiate and maintain an individual and accurate medical record for each patient receiving are in compliance with all federal and state laws and regulations… Each medical record will contain the following: … An updated medication profile to include medication, allergies, and/or sensitivities…”

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 observation, record review and interview, the Administrator / DON failed to be responsible for all day-to-day operations of the agency and failed to be responsible for implementing and supervising the administrative policies of the agency and administratively supervising the provision of all services. The Administrator / DON failed to ensure that the documentation of services provided was accurate and timely in 3 (Patients 1,2, and 3) of 3 patient records who the surveyor chose for home visits. The outcome was the clinical records were not available for the surveyor to review to determine if the plan of care was followed as ordered, and if the patient’s needs were being met. Patient’s care could be impacted when the agency failed to monitor if the plan of care was followed and was appropriate to meet the needs of the patients. Review of the Patient 1 clinical record on October 11, 2022, revealed a Plan of care for the certification 08/05/2022 to 10/03/2022 revealed orders for skilled nurse visits one time per week for 9 weeks plus two as needed for exacerbations of the disease processes. Review of the paper and electronic medical record documents revealed no documentation of clinical notes for skilled nurse visits scheduled for the weeks of 08/09/2022, 08/16/2022, 08/23/2022, no record of a resumption of care assessment or order for 09/21/2022, and no record of skilled nurse visits scheduled for the week of 09/27/22. The record contained documentation of a transfer to inpatient care on 08/24/2022 (during the third week of care). Record review revealed a referral from the skilled rehabilitation provider with a history and physical which listed current medications dated 08/04/2022. The list of medications did not include Ergocalciferol and Ferrous Sulphate. Record review of client 1’s clinical record revealed a medication profile for the period 10/04/2022 to 12/02/2022 and a comprehensive assessment completed by the Administrator / DON on 08/05/2022 at the start of care. Both documents contained medications Ergocalciferol and Ferrous Sulphate. During the home visit to Patient 1’s residence on 10/11/22 at 3 PM, the surveyor interviewed the patient. The surveyor observed and reviewed the medication containers provided by the patient and observed the Ergocalciferol and Ferrous Sulphate were not present in the patient’s medications. The surveyor reviewed the home folder left by the agency in the home and observed a list of medication which included Ergocalciferol, and Ferrous Sulphate was present in the home folder. The surveyor asked about the Ergocalciferol and Ferrous Sulphate. The patient stated they had not taken those medications for at least 6 months. The surveyor asked who came to the home from the agency. Patient 1 stated the DON or RN A. The surveyor asked how often nurses came to the home. Patient 1 stated every week. The surveyor reviewed the home folder left by the agency in the client’s home and noted a vital signs flow sheet was present. There were vital signs documented on 08/09/2022, 08/16/2022, 08/23/2022, 09/21/2022, and 09/27/2022. An interview was conducted with the Administrator / DON on 10/13/2022 at 11:30 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 1. The surveyor asked why the clinical record failed to contain notes for 08/09/2022, 08/16/2022, 08/23/2022, 09/21/2022, and 09/27/2022. The Administrator / DON stated: “I am still working on them. The surveyor asked what the agency’s policy was for completing the clinical notes. The Administrator / DON stated: “It should be done immediately, and “I try to have it (done) in 5 days.” The surveyor asked about the outcome of the deficient practice. The Administrator / DON stated: “It is a delay in the notes and does not affect the patient’s care.” The Administrator / DON stated that the care was not the problem, but “documentation is the problem” and that the nurse knew the patients and kept up with their care. The surveyor asked why the medications listed on the assessment and medication list contained medications Patient 1 stated she was not taking (Ergocalciferol and Ferrous Sulphate), and that the referring skilled rehabilitation list of current medications did not list. The Administrator / DON stated the electronic medical record software automatically put in medications and weights from previous assessments. The Administrator / DON stated the patient had been in and out of the hospital frequently, and the incorrect medications was because it wasn’t updated during the initial assessment. The surveyor asked about the outcome of the assessment being incorrect. The Administrator / DON stated that it should be updated and “I will fix it. I just missed it.” Record review of Patient 2’s clinical record revealed a medication profile for the certification period 09/26/2022 to 11/24/2022 which contained medications Topiramate and Ubrogepant. A plan of care completed by the Administrator / DON and dated 09/26/2022 also included medications Topiramate and Ubrogepant. During a home visit to Patient 2’s residence on 10/11/22 the surveyor observed and reviewed the medication containers provided by Client 2 and observed the topiramate and Ubrogepant were not present in the patient’s medications. In an interview with Patient 2 on 10/11/22 at 3:30 PM, the surveyor reviewed the medications and asked about the Topiramate and Ubrogepant. Patient 2 stated those were old medications they had previously taken for migraine headaches, and they had not taken them for at least 6 months since the injectable Emgality was started in April 2022. The surveyor reviewed the home folder left by the agency in the patient’s home and observed a list of medication which included Topiramate and Ubrogepant was present in the home folder. An interview was conducted with the Administrator / DON on 10/13/2022 at 11:40 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 2. The surveyor asked why the medications listed on the medication list and plan of care contained medications the patient stated she was not taking (Topiramate and Ubrogepant). The Administrator / DON stated the electronic medical record software automatically put in medications from previous assessments. The Administrator / DON stated the client had been discharged from the hospital in September 2022 after a fall in the home and a fractured her back, the client took a lot of medications for migraines, and the incorrect medications were because the medication list wasn’t updated during the initial comprehensive assessment. The surveyor asked about the outcome of the medication list being incorrect. The Administrator / DON stated that it should be updated and that she would correct the error. The Administrator / DON stated the client managed her own medications so there wasn’t an adverse outcome. Review clinical record for Patient 3 on October 11, 2022, revealed a Plan of care for the certification period 07/29/2022 to 09/26/2022 with orders for skilled nurse visits one time per week for 9 weeks plus on to two as needed for exacerbations of the disease processes. Review of the paper and electronic medical record documents revealed no documentation of clinical notes for skilled nurse visits scheduled for the weeks of 08/04/2022, 08/18/2022, 08/25/2022, 09/01/2022, 09/08/2022, and 09/15/2022. Record review of Patient 3’s clinical record revealed a Plan of Care and Medication Profile for the certification period 09/27/2022 to 11/25/2022 which also failed to contain 7 supplements (Reishi Mushroom, Estradius, Magnesium, Co Q 10, Vitamin C, Zinc, and a Multivitamin with iron) which the patient stated she took daily. During a home visit to Patient 3’s residence on 10/11/22 at 1:30 PM, the surveyor interviewed the patient. The surveyor asked who came to the home from the agency. Patient 3 stated RN A. The surveyor asked how often nurses came to the home. Patient 3 stated every week. Patient 3 stated she had problems with her blood pressure and the nurse took her blood pressure. The surveyor reviewed the home folder left by the agency in the home and noted a vital signs flow sheet was present. There were vital signs documented on 08/04/2022, 08/18/2022, 08/25/2022, 09/01/2022, 09/08/2022, and 09/15/2022. The surveyor reviewed the medication profile and plan of care copies in the home folder. The surveyor observed these documents were signed by RN A, dated 09/24/2022, and did not contain the 7 supplements (Reishi Mushroom, Estradius, Magnesium, Co Q 10, Vitamin C, Zinc, and a Multivitamin with iron). The surveyor asked about the supplements Patient 3 was taking. Patient 3 stated she took Reishi Mushroom, Estradius, Magnesium, Co Q 10, Vitamin C, Zinc, and a Multivitamin with iron) daily as recommended by her cardiologist. Patient 3 credited these supplements for her long life and stated she had taken these supplements for years. An interview was conducted with the Administrator / DON on 10/13/2022 at 11:50 AM. The surveyor reviewed the findings of the clinical record review and home visit findings for Patient 3. The surveyor asked why the medications listed on the medication list and plan of care did not contain a complete list that included the supplements taken by the patient. The Administrator / DON stated she had documented the supplements during one of her visits in the past and she “should have put them” on the medication list. The Administrator / DON didn’t know which visit note had the list with the supplements and said she would look for the note. The Administrator / DON stated the electronic medical record software automatically put in medications from the previous assessments and it should have been updated during the assessment. The surveyor asked about the outcome of the medication list being incomplete. The Administrator / DON stated that it should be updated and that she would contact the RN doing the visits to update the medication list. The surveyor asked if the medication list being incomplete was the reason the plan of care was also incomplete. The Administrator / DON stated: “Yes.” The surveyor asked why the clinical record failed to contain notes for 08/09/2022, 08/16/2022, 08/23/2022, 09/21/2022, and 09/27/2022. The Administrator / DON stated: “Those are RN A’s visits. I did talk to her about the notes. She hasn’t finished them yet.” The surveyor asked about the outcome of the deficient practice. The Administrator / DON stated that it was a delay in documentation, and they were behind in documentation. The surveyor asked how many clients RN A saw for the agency. The Administrator / DON stated: “Only that one. She has another job.” The Administrator / DON stated it was a delay in the notes and does not affect the patient’s care. Agency policy and procedure titled: “Medical Record Content IM.8” dated 10/01/2011 read in part: Policy – Agency will initiate and maintain an individual and accurate medical record for each patient receiving care … Each medical record will contain the following: …Height and weight as appropriate to patient care … Patient’s needs information, as documented in both initial assessments and ongoing assessments, which reflects: … An updated medication profile to include medication …Documentation of care provided …” Agency policy and procedure titled: “Timelines IM 10” dated 12/01/2014 read in part: “Policy – Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulations…. Daily progress notes with correlating time sheets are turned in within a maximum of 7 calendar days…. All clinical and progress notes will be written the day service is rendered… All medical record information will be incorporated into the patient’s medical record within 14 business days…. Agency policy and procedure titled: “Responsibilities of the Administrator LD.6” dated 04/01/2013 read in part: “Agency Administrator will assume overall responsibility and authority for administrative and leadership functions, supervision of the established organizational plan … The Administrator will be responsible for implementing and supervising the administrative policies and operations of the agency and for administratively supervising the provision of all services to agency patients on a day-to-day basis… Ensuring documentation of services is accurate and timely.