Every finding on record at Global Horizon Home Care

Unannounced visits were concluded at Global Horizon Home Care on 03/05/2025 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded on 03/05/25 at Global Horizon Home Care for the purpose of a recertification survey and a complaint investigation. A standard-level deficiency was identified.

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 reviews, review of agency documentation, interviews with agency personnel, and review of agency policies and procedures, for one of ten patient's (Patient #9) in the survey sample, the agency failed to perform the initial assessment visit for home care services within the prescribed time frame, and failed to follow the agency's policy for initial and comprehensive assessment visit. Patient # 9 had a start of care date of January 13, 2023 with diagnoses that included chronic heart failure (diastolic), chronic kidney disease, cirrhosis of the liver, anxiety, and hepatomegaly. The physician order for the certification period 1/13/25 through 3/13/25 included skilled nursing one time a week for nine weeks for nursing assessments, recognize and intervene to minimize complications, and a physical therapy evaluation for safety. Interview and review of Patient #9 clinical record and inpatient discharge paperwork with the Administrator on 3/6/25 at 1:30 pm, identified that Patient #9 was discharged from an inpatient unit on 1/9/25, with a physician order for a start of care for home care services on or before 1/11/25, but failed to identify completion of the physician ordered start of care visit until 2 days later, 1/13/25, (4 days from inpatient discharge) and failed to identify compliance with the agency policy. Review of the nursing communication note dated 1/11/25, identified that the admitting nurse was unable to locate the patient for completion of the initial assessment visit 1/11/25. Review of the agency Initial and Comprehensive policy identified the admission visit and initial assessment must be completed within 48 hours of a referral to home health services, or within 48 hours of the client's return home, or on a physician ordered start of care.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews, review of agency documentation, interviews with agency personnel, for one of ten patient's (Patient #9) in the survey sample, the agency failed to communicate a change in the start of care, initial assessment visit with the patient's physician. Patient # 9 had a start of care date of January 13, 2023 with diagnoses that included chronic heart failure (diastolic), chronic kidney disease, cirrhosis of the liver, anxiety, and hepatomegaly. The physician order for the certification period 1/13/25 through 3/13/25 included skilled nursing one time a week for nine weeks for nursing assessments, recognize and intervene to minimize complications, and a physical therapy evaluation for safety. Interview and review of Patient #9 clinical record and inpatient discharge paperwork with the Administrator on 3/6/25 at 1:30 pm, identified that Patient #9 was discharged from an inpatient unit on 1/9/25, with a physician order for a start of care for home care services on or before 1/11/25, but failed to identify completion of the physician ordered start of care visit until 2 days later, on 1/13/25, (4 days after inpatient discharge). Review of the communication note dated 1/11/25, identified that the admitting nurse was unable to locate the patient for completion of the initial assessment visit 1/11/25, but failed to identify communication with the physician related to the missed visit and for a change in the start of care date.

An unannounced visit concluded on March 25, 2024 at Global Horizon Homecare in Bloomfield for the purpose of a complaint investigation. Standard-level deficiencies were identified.

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, review of agency policies and interview with agency personnel, for one of two patients (Patient #1) in the survey sample, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs and failed to follow physician’s orders. Patient #1 had a start of care date of 9/22/23 and diagnoses that included hemiplegia following a cerebral infarct affecting the right dominant side, type II diabetes mellitus and hypertension. The physician's orders for the certification period of 11/21/23 through 1/19/24 included nursing services twice daily for medication and insulin administration and assessments. i. Interview and review of the clinical record with the Administrator on 3/25/24 at 11 AM identified Patient #1 was receiving home health aide services seven days a week, although, review of the physician’s orders failed to identify home health aide services were included in the plan of care. Physician’s orders included Lantus Solostar pen 100 u/ml inject 29 units subcutaneously every twelve hours daily. ii. Interview and review of the November 2023 through February 2024 MAR’s with the Administrator on 3/25/24 at 2 PM, identified the Lantus insulin was administered in the “AM” and “PM”, but failed to identify specific times of administration and review of the twice daily nursing notes from November 2023 through February 2024 identified that the nurses visited between 8-9 AM and 5-6 PM daily and failed to follow physician’s orders for the Lantus insulin administration every twelve (12) hours. Review of the agency’s policy for Care Planning, identified clinicians would inform the patient’s physician of any changes that suggest a need to alter the plan of care. Changes would be written, dated, and signed by the qualified clinician and physician making the changes.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for one of two patients (Patient #1) in the survey sample, the agency licensed nurses failed to communicate with the physician the need to clarify the interval of insulin administration. The findings include: Patient #1 had a start of care date of 9/22/23 and diagnoses that included hemiplegia following a cerebral infarct affecting the right dominant side, type II diabetes mellitus and hypertension. The physician's orders for the certification periods of 9/22/23 through 3/19/24 included nursing services twice daily for medication and insulin administration and assessments and home health aide services to assist with personal care. Physician’s orders included Lantus Solostar pen 100 u/ml inject 29 units subcutaneously every twelve hours daily. Interview and review of the November 2023 through February 2024 MAR’s with the Administrator on 3/25/24 at 2 PM identified the Lantus insulin was administered in the “AM” and “PM”, failed to identify specific times of administration and review of the twice daily nursing notes from November 2023 through February 2024 identified that the nurses visited between 8-9 AM and 5-6 PM daily. Furthermore, the Administrator identified that the patient requested morning visits after 8 AM, but failed to communicate the request to the physician, and failed to clarify the insulin order from every 12 hours to twice daily at breakfast and dinner. Review of the agency’s policy for Care Planning, identified clinicians would inform the patient’s physician of any changes that suggest a need to alter the plan of care. Changes would be written, dated, and signed by the qualified clinician and physician making the changes.

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 clinical record review and interviews with agency personnel for one of two patients (Patient #1) in the survey sample, the agency failed to ensure an accurate and authentic record. The findings include: Patient #1 had a start of care date of 9/22/23 and diagnoses that included hemiplegia following a cerebral infarct affecting the right dominant side, type II diabetes mellitus and hypertension. The physician's orders for the certification periods of 9/22/23 through 3/19/24 included nursing services twice daily for medication and insulin administration and assessments and home health aide services to assist with personal care. Physician’s orders included Humalog insulin 100 units/milliliter (u/ml) injectable subcutaneously (15 units) per sliding scale with meals and Lantus Solostar pen 100 u/ml, inject 29 units subcutaneously every twelve hours daily. Review of the November Medication Administration Record/MAR identified Humalog insulin 35 units was administered with breakfast and 25 units administered with lunch and dinner and Lantus insulin 29 units administered in the morning and evening. Interview and review of LPN #1’s twice daily nursing notes from 11/01/23 to 11/30/23 with the Administrator on 3/25/24 at 10 AM identified the twice daily administration of Humalog insulin, 25 units and Lantus insulin 45 units and failed to ensure an accurate record of the insulin doses given in accordance with the MAR.

Unannounced visits concluded on 5/30/2023, 05/31/2023, 06/01/2023 and 06/05/2023 at Global Horizon Home Care for the purpose of a complaint investigation. Standard-level deficiencies were identified.

Rights of the patient CFR(s): 484.50(c) The patient has the right to- This STANDARD is not met as evidenced by: Based on review of clinical records and interviews with agency personnel for one of eight patients in the survey sample (Patient #7) the agency failed to maintain the Patient’s rights during the discharge process. The findings included: Patient #7 had a start of care date of 11/06/2017 with bipolar disorder, intellectual disabilities, type II diabetes, and long-term use of insulin. The physician’s orders for the certification period of 04/09/2023 to 06/07/2023 included twice daily nursing visits for medication administration and nursing assessments. Interview and review of Patient #7’s clinical record from 04/09/2023 to 05/16/2023 with the Administrator on 06/05/2023 at 12:22 PM, identified the Patient was referred to an alternate home health agency (agency #2) by Physician #1 on 05/15/2023. Home Health Agency #2 completed a start of care on 05/17/2023. The Administrator became aware Home Health Agency #2 completed a start of care on 05/17/2023 but declined to discharge the Patient. Physician #1 and Department of Developmental Services (DDS) Case Manager #1 again requested Patient #7’s discharge from the agency which occurred on 05/24/2023. Interview and review of Patient #7’s clinical record with Physician #1 on 06/05/2023 at 1:30 PM, identified Patient #7 was referred to Home Health Agency #2 on 05/15/2023. During an office visit with Physician #1, the Patient and DDS Case Manager #1 indicated the current agency frequently missed visits and administered bedtime medications to the Patient in the early afternoon resulting in lethargy. Therefore, Physician #1 referred Patient #7 to an alternate agency and attempted to contact the Patient’s current agency to request discharge but did not receive return communication.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on review of clinical records, interviews with agency personnel and agency policies for one of eight patients in the survey sample (Patient #7) the agency failed to have a Registered Nurse (RN) complete the comprehensive recertification assessment of the Patient. The findings included: Patient #7 had a start of care date of 11/06/2017 with bipolar disorder, intellectual disabilities, type II diabetes, and long-term use of insulin. The physician’s orders for the certification period of 04/09/2023 to 06/07/2023 included twice daily nursing visits for medication administration and nursing assessments. Interview and review of Patient #7’s clinical record from 04/09/2023 to 05/16/2023 with the Administrator on 06/05/2023 at 12:00 PM, identified Licensed Practical Nurse (LPN) #1 completed twice daily visits on 04/05/2023 and Registered Nurse #1 completed a recertification visit ( a visit from an RN completed every sixty (60) days to attest the Patient is still eligible for home health services) on 04/05/2023. The Administrator identified Patient #7 declined an on-site recertification visit from RN #1, therefore, LPN #1 provided the assessment information to RN #1. Additionally, the Administrator failed to identify Patient #7’s physician was notified of the Patient’s refusal for an on-site RN recertification visit. Review of the agency’s policy for Care Planning, identified the frequency of the review of the plan of care would be based on changes in the Patient’s health status, needs and the environmental factors affecting care. The primary care manager would be responsible for revising the plan of care or updating the plan every sixty (60) days.

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 review of clinical records, interviews with agency personnel and agency policies for one of eight patients in the survey sample (Patient #7) the agency failed to follow a physician ordered plan of care. The findings included: Patient #7 had a start of care date of 11/06/2017 with bipolar disorder, intellectual disabilities, type II diabetes, and long-term use of insulin. The physician’s orders for the certification period of 04/09/2023 to 06/07/2023 included twice daily nursing visits for medication administration and nursing assessments. Patient #7 was prescribed the following medications to be administered at bedtime: Perphenazine 4 milligrams (mg) one tab with an 8 mg dose for a total of 12 mgs at bedtime, Hydroxyzine 100 mg at bedtime, Caplyta 42 mg at bedtime and Trileptal 600 mg 1 ½ tablets at bedtime. Interview and review of Patient #7’s clinical record from 04/09/2023 to 05/16/2023 with the Administrator on 06/05/2023 at 11:45 AM, identified Patient #7 was seen by Licensed Practical Nurse (LPN) #1 twice per day for medication administration around 08:45 AM and 3:45 PM each day. The Administrator indicated Patient #7 requested administration of bedtime medications in the early afternoon by LPN #1 but failed to identify LPN #1 administered the medications as prescribed and failed to identify the Patient’s physician was notified of changes in administration times. Review of the agency’s policy for Care Planning, identified clinicians would inform the Patient’s physician of any changes that suggest a need to alter the plan of care. Changes would be written, dated, and signed by the qualified clinician and physician making the changes.

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 review of clinical records, interviews with agency personnel and agency policies for one of eight patients in the survey sample (Patient #7) the agency failed to communicate a change in a Patient’s condition to the physician as directed by the plan of care. The findings included: Patient #7 had a start of care date of 11/06/2017 with bipolar disorder, intellectual disabilities, type II diabetes, and long-term use of insulin. The physician’s orders for the certification period of 04/09/2023 to 06/07/2023 included twice daily nursing visits for medication administration, assessment of diabetic status and notifying the physician if the Patient’s fasting blood glucose was below seventy or above one hundred eighty or if the random blood glucose was below seventy or above two hundred. Interview and review of Patient #7’s clinical record from 04/09/2023 to 05/16/2023 with the Administrator on 06/05/2023 at 11:45 AM, failed to identify the Patient’s physician was notified of the following elevated random blood glucose levels of 213, 218, 219, 242, 244, 273, 281, 289, 291, 305, 310, 315, 319, 329, 356, 376 and 379. Review of the agency’s policy for Care Planning, identified clinicians would promptly notify a Patient’s physician of any significant changes observed or reported in the Patient’s condition.

Unannounced visits were concluded at Global Horizon Homecare, Inc. on 3/02/2022 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits were concluded at Global Horizon Homecare, Inc. on 3/02/2022 for the purpose of recertification and re-licensure. Standard-level deficiencies were identified.

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 interview with agency personnel, for one of ten patients (Patient #6 ) in the survey sample, the agency nurse failed to ensure the plan of care addressed the patient’s individual needs and/or failed to follow the physician-certified plan of care. The findings include: Patient #6 had a start of care date of 2/17/22 and diagnoses that included liver abscess, type II diabetes mellitus and end stage renal disease. The physician's orders dated 2/17/22 included nursing services for assessments, diabetic teaching, home health aide services to assist with personal care, physical therapy and occupational therapy services The initial nursing assessment dated 2/17/22 identified the presence of a Jackson-Pratt/JP drain (a closed-suction medical device used as a post-operative drain for collecting body fluids from surgical sites) in the patient’s right lower abdomen. a. Interview and review of the clinical record with the Administrator on 3/02/22 at 10:30 AM failed to ensure the care plan addressed the need to change the dressing over the JP drain site and/or the frequency of draining the JP device. b. Interview and review of the clinical record with the Administrator on 3/02/22 at 11 AM failed to identify that a home health aide was provided (thirteen days after the start of care) and failed to follow the physician-certified plan of care.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on observations, review of the clinical record, interviews and review of agency polices for one of one patients (Pt#3) who required twice daily medication administration that included a controlled substance medication, and /or for one of two patient (Patient #6) requiring Occupational Therapy Services the agency nurse failed to follow the agency Controlled Substance policy and /or start of care assessment policy. The findings: a.Patient #3 had a start of care date of 9/29/2021 and diagnoses that included bipolar disorder, intermittent explosive and borderline personality disorder. The physician's orders for the certification period of 1/27/22 through 3/27/22 included nursing services twice daily for medication administration. The patient's medication included Ativan 0.5 milligram (mg) 1 tablet twice daily as needed, for anxiety. During a joint visit with Registered Nurse/RN#2 on 3/1/22 at 8:00 am, RN#2 was observed to pre-pour all patient's medication, including Ativan 0.5 mg 1 tablet, at Patient#3's request. RN#2 then handed the pre-poured medications to the patient for self administration. The patient swallowed the medications without any issues, and requested the nurse to come back around 7:00 p.m. for an evening administration. Interview with the Administrator on 3/2/22 at 1:00 pm identified that RN#2 did not know that Ativan was considered a Controlled Substance, and failed to complete the agency required medication count, at each visit, in accordance agency policy. The agency policy on Controlled Substance directed a count of all Controlled substances by the nurse and patient at each visit. b. Patient #6 had a start of care date of 2/17/22 and diagnoses that included liver abscess, type II diabetes mellitus and end stage renal disease. The physician's orders dated 2/17/22 included nursing services for assessments and diabetic teaching, home health aide services to assist with personal care, physical therapy and occupational therapy services. Interview and review of the clinical record with the Administrator on 2/28/22 at 12:15 PM identified an initial occupational therapy evaluation dated 2/27/22 (ten days after the start of care) and failed to follow agency policies for initial assessments within five days after the start of care.

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 review of the clinical record, review of agency policies and interview with agency personnel, for two of ten patient’s (Patient’s #6 and #8 ) in the survey sample, the agency licensed nurses failed to provide the necessary assessments. The findings include: b. Patient #8 had a start of care date of 12/15/2020 and diagnoses that included end stage renal disease, type II diabetes mellitus and chronic obstructive pulmonary disease. The physician's orders for the certification period of 2/8/22 through 4/8/2022 included nursing services once a week for vital signs and general assessments, and patient education regarding dialysis side effects, and aide services two times a day for 60 days for assistance with the activities of daily living. On 2/03/21, RN#4 documented on OASIS Recertification documentation that the patient had an AV (arteriovenous) fistula. Review of nursing notes dated 12/7/21, 12/11/21 and 2/24/22 with the Administrator on 3/2/22 at 1:45 pm identified that the nursing visits were completed, but failed to identify the assessment of AV fistula for the presence of a thrill and bruit. a. Patient #6 had a start of care date of 2/17/22 and diagnoses that included liver abscess, type II diabetes mellitus and end stage renal disease. The physician's orders dated 2/17/22 included nursing services for assessments and diabetic teaching, home health aide services to assist with personal care, physical therapy and occupational therapy services. The initial nursing assessment dated 2/17/22 identified the presence of a Jackson-Pratt/JP drain (a closed-suction medical device used as a post-operative drain for collecting body fluids from surgical sites) in the patient’s right lower abdomen. Review of RN #1’s nursing notes dated 2/21/22 and 2/25/22 with the Administrator on 3/02/22 at 10:30 AM failed to identify an assessment of the skin around the JP drain site and/or the fluid color and amount inside the JP drainage system. Review of agency policy documentation, directed nursing staff to utilize the Lippincott or VNAA Clinical Procedure Manual for protocols that defined specific assessment techniques.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for two of ten patient's (Patients #6 and Patient #8) in the survey sample, the agency licensed nurses failed to communicate with the physician the need for management of a JP drain and/or the need to pre-pour medications. The findings include: a. Patient#8 had a start of care date of 12/15/2020 and diagnoses that included end stage renal disease, type II diabetes mellitus and chronic obstructive pulmonary disease. The physician's orders for the certification period of 2/8/22 through 4/8/2022 included nursing services once a week for vital signs, general assessments, patient education regarding dialysis side effects, and aide services two times a day for 60 days for assistance with the activities of daily living. On 12/7/21, RN#3 documented on OASIS Recertification note that the patient's apartment was "neat, but soiled with roaches present. The niece was notified". On 2/3/22, RN#4 documented on OASIS Recertification noted that the patient's apartment was "neat, but soiled with roaches present. The niece was notified". Interview and review of the clinical record with the Administrator on 3/2/22 at 1:45 pm failed to identify nursing communication with the physician regarding the need for social work involvement, to assess for possible resource agencies to assist patient with needs. b. Patient #6 had a start of care date of 2/17/22 and diagnoses that included liver abscess, type II diabetes mellitus and end stage renal disease. The physician's orders dated 2/17/22 included nursing services for assessments and diabetic teaching, home health aide services to assist with personal care, physical therapy and occupational therapy services. The initial nursing assessment dated 2/17/22 identified the presence of a Jackson-Pratt/JP drain (a closed-suction medical device used as a post-operative drain for collecting body fluids from surgical sites) in the patient’s right lower abdomen. i. Interview and review of the clinical record with the Administrator on 3/02/22 at 10:30 AM failed to identify physician communication of the need to change the dressing over the JP drain site and/or the frequency of draining the JP device. ii. Interview and review of RN #1’s nursing notes dated 2/21/22 and 2/25/22 with the Administrator on 3/02/22 at 12 PM identified that the patient’s medications were pre-poured for seven days but failed to identify physician communication of the need for medication pre-pouring assistance.

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 clinical record review, interviews with the agency staff and policy review for one of three patients (Patient #2) who required weekly medication pre-pour and/or for one of ten patient's (Patient #6) in the survey sample, the agency administrator failed to develop a comprehensive policy on medication pre-pour documentation that included a reference source used for a pre-pour and/or ensure occupational therapy and home health aide services were delivered in a timely manner in accordance with physician's orders. The findings include: Patient#2 had a start of care date of 10/25/21 and diagnoses that included hypertension, type II diabetes mellitus and atrial fibrillation. The physician's orders for the certification period of 12/14/21 through 2/11/22 directed nursing services once a week for medication pre-pour and general assessments. Review of RN#3's notes dated 12/19/21, 12/28/21, 1/24/22, 1/31/22 and 2/7/22 identified that RN#3 documented that he/she pre-poured medications "from" and "to" period and documented a reference source as a medication profile used for pre-pour. Review of Licensed Practical Nurse/LPN#1 notes dated 1/3/22, 1/10/22 and1/17/22 identified that LPN#1 documented that he/she pre-poured medication "from" and "to" period and did not document a reference source. Interview and review of RN#3 notes, LPN#1 notes, and the agency policy on documentation of medication pre-pour with the Administrator on 3/2/22 at 1:15 pm identified that the nurses documented medications were pre-poured, but failed to identify that the agency policy required to document a reference source used to document a medication pre-pour to ensure the accuracy of a medication pre-pour. The agency policy on Medication pre-pour, directed nursing staff, to mark pre-pour(pp) in the days in which medication were pre-poured along with nursing initials. Nurses who pre-pour medications should sign their name, title and initials on the bottom of the Medication Administration Record (MAR). Patient #6 had a start of care date of 2/17/22 and diagnoses that included liver abscess, type II diabetes mellitus and end stage renal disease. The physician's orders dated 2/17/22 included nursing services for assessments and diabetic teaching, home health aide services to assist with personal care, physical therapy and occupational therapy services. a. Interview and review of the clinical record with the Administrator on 2/28/22 at 12:15 PM identified an initial occupational therapy evaluation dated 2/27/22 (ten days after the start of care) failed to provide an explanation of the delay in services and failed to ensure OT services were provided in a timely manner. b. Interview and review of the clinical record with the Administrator on 3/02/22 at 11 AM failed to identify that a home health aide was provided (thirteen days after the start of care). The Administrator indicated that s/he thought the home health aide services were declined, although review of the clinical record lacked documentation of the declination of home health aide services, and failed to ensure home health aide services were provided in a timely manner.

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 clinical record review, interviews with the agency staff and review of the agency policy for one of three patients (Pt#10) who were discharged from the agency, the agency nurses failed to ensure the patient's clinical record was accurate. The finding includes: Patient#10 had a start of care date of 10/21/21 and diagnoses that included type II diabetes mellitus, hypertension, and depression. The physician's orders for the certification period of 10/23/21 through 12/19/21 included nursing services once a week for general assessments and education. Review of RN#1's note dated 10/21/21 identified that the nurse completed the start of care visit. Review of LPN#2's notes dated 10/25/21 and 11/1/21 identified that the patient cancelled the visits, the patient's physician and the agency office were notified of the cancelation. Review of LPN#3's note dated 11/11/21 identified that the patient refused the visit, the patient's physician was notified. Review of the communication note dated 11/15/21 identified that the patient's case manager was notified that the patient refused the three nursing visits since the start of care visit of 10/21/21. Review of RN#1's LPN supervisory visit note dated 11/15/21 identified that the patient was happy with the services. Review of LPN#2 note dated 11/29/21 identified that the patient no longer wanted nursing services, the physician was notified. The patient was discharged from the agency on 12/7/21. Interview and review of the nursing notes with the Administrator on 3/2/22 at 1:30 pm identified that the patient was initially seen by RN#1 on 10/21/21, and that the patient refused three subsequent visits by LPNs, but failed to ensure that the patient's clinical record was complete and accurate. The agency policy on Clinical Records, identified that the clinical record would be accurate and adhere to the current clinical record documentation standards of practice.