Every finding on record at Good Samaritan Society-Home Care

Indianola, Iowa · CCN 167416

18 findings across 2 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of February 6, 2025

5 findings

E0000

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 2/3/25 through 2/6/25 the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness

G0000

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 2/3/25 through 2/6/25. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 43 patients at the time of the survey.

G0574

G0590

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 observations, patient and staff interviews, record review and policy review, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 1 of 7 sampled patients. (Patient #5) Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Care Planning and Care Coordination, dated 9/23/24: Collaboration ad communication relevant to the patients care should be ongoing and include the team, the physician, and the patient /support system. The Plan of Care (POC) must be reviewed and revised by the provider as frequently as the patient's condition requires. Significant changed in the patients condition are communicated in a timely manner and documented in the patient record. During an interview on 2/6/25, at 1:30 PM, the Administrator reported the parameters for vital signs are included in the POC, and any vital sign readings outside of those parameters need to be reported to the physician. The Administrator also reported orthostatic blood pressure readings (blood pressure readings that are taken sitting down and then upon standing to see if there is a significant drop in the readings) are attempted on all patients when possible as part of a quality program to reduce hospitalizations. The Home Health Aides (HHA) are educated and are checked off on the skill of obtaining orthostatic blood pressure readings. The HHA's are also educated on the parameters and carry laminated cards to know when those readings are outside of the parameters indicating the HHA need to notify the Registered Nurse (RN) Case Manager. 1.Patient #5 had a start of care date of 12/26/24 with a primary diagnosis of congestive heart failure (CHF). Clinical record revealed the following: a. The POC dated 12/26/24 to 2/4/25 included physician orders to call if blood pressure readings were greater than 160/90 or or less than 90/50. b. Home Health Aide Note dated 12/30/24, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 165/70 and upon standing 181/76, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. c. Home Health Aide Note dated 1/6/25, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 195/78 and upon standing 189/95, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. d. Home Health Aide Note dated 1/13/25, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 185/86 and upon standing 194/86, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. e. Home Health Aide Note dated 1/28/25, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 171/76 and upon standing 165/78, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. The agency failed to alert the physician of vital signs outside of the ordered parameters. The above findings were reviewed with the agency Administrator.

G1024

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 observation, agency staff interviews, clinical record review and policy review, the agency failed to ensure agency staff properly authenticated all clinical entry notes and/or completed within the agency's expected timeframe for 7 of 7 sampled patients. (Pt #1, #2, #3, #4, #5, #6, and #7) Failure to ensure all clinical record documentation was dated, timed and signed with staff title and/ or completed within the agency's expected timeframe, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the agency policy titled Documentation Standards, Home Health, Therapy / Rehab - Enterprise, dated 3/4/24, authentication of medical records must include a signature and a title, or a secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry. During an interview on 2/6/25, at 2:00 PM, the Administrator stated the expectation for credentials in the Electronic Medical Record (EMR) for staff, is an electronic signature which includes the date, time, name and title/credentials for each entry in to the EMR. 1.Patient #1 had a start of care date of 1/15/25. Clinical record review revealed the following: a. The Skilled Nurse (SN) initial comprehensive assessment dated 1/15/25, completed by Staff B, Registered Nurse (RN) , included a clinician signature, but lacked a completion date / time and clinician credentials. b. The initial Physical Therapy (PT) evaluation dated 1/23/25, completed by Staff E, Physical Therapist (PT), included clinician signature, date and time, but lacked clinicians credentials. c. The PT service notes dated 1/29/25, 1/31/25 and 2/3/25 completed by Staff G, PT, included clinician signature, date and time, but lacked clinicians credentials. d. The initial Occupational Therapy (OT) evaluation dated 1/23/25, completed by Staff F, Occupational Therapist (OT), included clinician signature, date and time, but lacked clinicians credentials. 2. Patient #2 had a start date of 12/25/24. Clinical record review revealed: a. The initial OT Evaluation dated 1/2/25, completed by Staff F, OT, included clinician signature, date and time, but lacked clinician credentials. b. The OT service notes dated 1/6/25 and 1/25/2/5, completed by Staff F, OT, included clinician signature, date and time, but lacked clinicians credentials. c. The OT service notes dated 1/8/25 and 1/15/25, completed by Staff H, OT, included clinician signature, date and time, but lacked clinicians credentials. d. The initial PT evaluation dated 12/31/24, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. e. The PT service note, dated 1/8/25, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. 3. Patient #3 had a start of care date of 3/6/2024. Clinical record review revealed the following: a. The SN service notes dated 1/27/25, 1/29/25, 2/3/25 and 2/5/25, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. 4. Patient #4 had a start of care date of 7/12/24. Clinical record review revealed the following: a. The initial comprehensive assessment dated 7/12/24, completed by Staff I, RN, included clinician signature, date and time, but lacked clinicians credentials. b. The recertification comprehensive assessment completed on 9/5/24 by staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. c. The comprehensive assessment for resumption of care completed on 1/27/25, Staff B, RN , included clinician signature, date and time, but lacked clinicians credentials. 5. Patient #5 had a start of care date of 12/26/24. Clinical record review revealed the following : a. Clinical nursing notes dated 12/27/24, 1/2/25, 1/10/25 and 1/21/25, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. 6. Patient #6 had a start of care date of 12/6/2024 and a discharge date of 1/3/2025. Clinical record review revealed the following: a. The initial OT evaluation note dated 12/11/24, completed by Staff F, included clinician signature, date and time, but lacked clinicians credentials. b. The OT service note dated 12/20/24, and 1/1/25, completed by Staff H, included clinician signature, date and time, but lacked clinicians credentials. c. The OT service noted dated 1/8/25, completed by Staff F, included clinician signature, date and time, but lacked clinicians credentials. d. The Initial PT evaluation dated 12/12/24, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. e. The discharge PT summary note, dated 1/31/25, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. 7. Patient # 7 had a start of care date of 6/18/2024 and a discharge date of 9/24/24. Clinical record review revealed the following: a. The comprehensive assessment for recertification note dated 8/15/24, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. b. The SN service note dated 9/11/24, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. c. The PT service note dated 8/11/24, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. d. The SN discharge assessment, dated 9/24/24, completed by Staff B, included clinician signature, date and time, but lacked clinicians credentials. The agency failed to ensure all clinical record documentation was dated, timed and signed with clinician name and credentials. The above findings were reviewed with the agency Administrator.

Survey of February 16, 2022

13 findings

E0000

The recertification survey, conducted from 2/14/2022 through 2/16/2022, found the agency operating in substantial compliance with the requirements of the Appendix Z Establishment of Emergency Preparedness. The agency reported a census of 57 patients at the time of the survey.

G0000

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 2/14/2022 through 2/16/2022, found the agency operating out of compliance with the following standard level deficient practices: The agency reported a census of 57 patients at the time of the survey.

G0440

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 review and staff interview, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 4 of 5 sampled patients admitted since the last survey on 2/13/2019 and receiving services paid for by a federally-funded payer. (Patients #1, #4, #5 and #7). Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: 4. Patient #5 had a start of care date of 11/6/19. Clinical record review revealed the following: The patient's Admission and Service Agreement was dated as signed by Patient #5 on 11/6/2019. The document identified planned skilled nurse visits to assess and manage medications for the patient once every other week; the agency planned to bill the Veteran's Administration for the agency services and the charge for the service would be $180.00 per visit and planned home health aide visits for bathing and personal cares for the patient three times per week; the agency planned to bill the Veteran's Administration for the agency services and the charge for the service would be $85.00 per visit. The Veteran's Administration is a federally funded program. The document identified the total fee for services but the form did not identify in writing how much the patient could expect to pay out of pocket for the planned services. The surveyors reviewed the above findings with the agency Administrator/Clinical Manager and Office Manager. Agency staff provided no additional information prior to the end of the survey. The agency's Admission and Service Agreement form included the statement "I have been informed of my rights and responsibilities in writing. I have read (or they have been explained to me) and understand them." The form included a blank space for the agency clinician to hand write in a description of the services provided, each discipline who will provide care and the planned frequency of visits for each; the payer source billed for the services; and the charge per visit/hour. 1. Patient #1 had a start of care date of 3/9/2020. Clinical record review revealed the following: The patient's Admission and Service Agreement was dated as signed by Patient #1 on 3/9/2020. The document identified planned skilled nurse visits to assess and manage medications for the patient once every other week; the agency planned to bill the Veteran's Administration for the agency services and the charge for the service would be $180.00 per visit. During agency staff interview on 2/15/2022 at 12:55 PM, the Administrator/Clinical Manager reviewed the patient's Admission and Service Agreement with the surveyor. The Administrator/Clinical Manager reported the Veteran's Administration pays 100% for patient care. She stated "The form should be $0 for each visit- the nurse put in the full fee for (for skilled nursing services) instead. But I do let each patient know over the phone with referral to be sure they know upfront." The Veteran's Administration is a federally funded program. The document identified the total fee for services but the form did not identify in writing how much the patient could expect to pay out of pocket for the planned services. 2. Patient #4 had a start of care date of 10/15/2021. Clinical record review revealed the following: The patient's Admission and Service Agreement was dated as signed by Patient #4 on 10/15/2021. The document identified planned skilled nurse visits for general assessment once weekly for 4 weeks; planned physical therapy visits for strengthening twice weekly for 4 weeks; the agency planned to bill Medicare for the skilled nursing and physical therapy services and the charge for the service would be $200.00 per hour for each skilled nurse visit and $210.00 per hour for each physical therapy visit. During agency staff interview on 2/15/2022 at 12:55 PM, the Administrator/Clinical Manager reviewed the patient's Admission and Service Agreement with the surveyor. The Administrator/Clinical Manager reported Medicare pays 100% for patient care. She stated "The form should be $0 for each visit- the nurse put in the full fee for (for skilled nursing and physical therapy services) instead. But I do let each patient know over the phone with referral to be sure they know upfront." Medicare is a federally funded program. The document identified the total fee for services but the form did not identify in writing how much the patient could expect to pay out of pocket for the planned services. 3. Patient #7 had a start of care date of 12/8/2021. Clinical record review revealed the following: The patient's Admission and Service Agreement was dated as signed by Patient #7 on 12/8/2021. The document identified planned skilled nurse visits for general assessment once every other week; planned physical therapy visits for home exercise program 1-3 times weekly; planned occupational therapy visits for home exercise program; the agency planned to bill Medicare for the skilled nursing, physical therapy and occupational therapy services and the charge for the service would be $200.00 per hour for each skilled nurse visit and $210.00 per hour for each physical therapy and occupational therapy visit. During agency staff interview on 2/15/2022 at 12:55 PM, the Administrator/Clinical Manager reviewed the patient's Admission and Service Agreement with the surveyor. The Administrator/Clinical Manager reported Medicare pays 100% for patient care. She stated "The form should be $0 for each visit- the nurse put in the full fee for (for skilled nursing and physical therapy services) instead. But I do let each patient know over the phone with referral to be sure they know upfront." Medicare is a federally funded program. The document identified the total fee for services but the form did not identify in writing how much the patient could expect to pay out of pocket for the planned services.

G0536

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of the initial and update to the comprehensive assessment for 4 of 8 sampled patients (Patients #1, #2, #7 and #8). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: 4. Patient #2 had a start of care date of 1/3/2022. Clinical record review revealed the following: The initial comprehensive assessment at the time of start of care, dated 1/3/2022, lacked documentation of a drug regimen review. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the start of care assessment in the Medication Evaluation section. The surveyors reviewed the above findings with the agency Administrator/Clinical Manager. Agency staff provided no additional information prior to the end of the survey. According to the agency policy, titled Comprehensive Assessment- Home Health, Therapy and Rehab and dated 2/8/2022, the drug regimen review is required as part of each comprehensive assessment. According to the agency policy, titled Medication Management, Home Care and Hospice, the clinician will reconcile the patient's medications at start of care, resumption of care, recertification, discharge and whenever medication is added, discontinued or changed. A comprehensive assessment of medications may included prescription medications, over-the-counter medications and herbal remedies currently taken by the patient. The medications will be reviewed to identify any potential/actual major interactions or side effects; ineffective medication therapy; duplicate drug therapy; drug/food interactions; and patient non-compliance with medications as ordered or directed. During agency staff interview on 2/14/2022 at 9:35 AM, the Administrator/Clinical Manager reported the clinicians assess all medications at the time of admission and with each recertification, enter the medications into the patient's electronic medical record, reconcile all of the medications and document the drug regimen review in the Medication Evaluation section within the agency's electronic clinical record system. 1. Patient #1 had a start of care date of 3/9/2020. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of recertification, dated 3/2/2021, lacked documentation of a drug regimen review. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the recertification assessment in the Medication Evaluation section. b. The update to the comprehensive assessment at the time of recertification, dated 8/26/2021, included documentation of a drug regimen review. The review documented no duplicate medication therapy or potential medication interactions were found. The Plan of Care, dated 8/31/2021 to 10/29/2021, included the following medications: low dose aspirin and Eliquis, both blood thinners; metoprolol and furosemide, both taken to lower the blood pressure; gabapentin, tramadol and acetaminophen, all three taken for pain relief. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the recertification assessment in the Medication Evaluation section. The clinician failed to identify the duplicate blood thinners and the potential for abnormal bleeding when combined; failed to identify the duplicate blood pressure medications and the potential for hypotension when combined; and failed to identify the duplicate pain medications. c. The update to the comprehensive assessment at the time of recertification, dated 12/28/2021, lacked documentation of a drug regimen review. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the recertification assessment in the Medication Evaluation section. 2. Patient #7 had a start of care date of 12/8/2021 and was discharged from agency services on 1/20/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 1/20/2022, lacked documentation of a drug regimen review. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the discharge assessment in the Medication Evaluation section. 3. Patient #8 had a start of care date of 9/2/2020. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of recertification, dated 4/29/2021, lacked documentation of a drug regimen review. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the recertification assessment in the Medication Evaluation section. The Medication Evaluation section did included documentation of a drug regimen review, dated 5/4/2021; however, the Plan of Care certification period associated with the comprehensive assessment was dated 3/1/2021 to 4/29/2021. The 5/4/2021 drug regimen review was completed outside of the allowed time frame for the certification period ending on 4/29/2021 so could not be associated with the 4/29/2021 assessment. b. The update to the comprehensive assessment at the time of recertification, dated 8/26/2021, lacked documentation of a drug regimen review. The patient's electronic clinical record lacked documentation of a drug regimen review associated with the recertification assessment in the Medication Evaluation section.

G0546

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 agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 3 of 5 sampled patients requiring a recertification assessments (Patients #3, #5 and #8). Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: 3. Patient #8 had a start of care date of 9/2/2020. Clinical record review revealed the following: a. The Plans of Care, dated 3/1/2021 to 4/29/2021 and 4/30/2021 to 6/28/2021, included physician orders for home health aide only services for bathing and personal care. An update to the comprehensive assessment at the time of recertification was dated as initiated on 4/29/2021 and electronically signed as completed on 5/4/2021. The assessment was not completed by day 60 as required by regulation and agency policy, making the assessment 5 days late. b. The Plans of Care, dated 10/27/2021 to 12/25/2021 and 12/26/2021 to 2/23/2021, included physician orders for home health aide only services for bathing and personal care. An update to the comprehensive assessment at the time of recertification was dated as initiated on 12/23/2021 and electronically signed as completed on 12/27/2021. The assessment was not completed by day 60 as required by regulation and agency policy, making the assessment 2 days late. The surveyors reviewed the above stated findings with the Administrator/Clinical Manager and the Office Manager. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Comprehensive Assessment Policy and dated 2/8/22, a comprehensive assessment fmust be updated any time there is a major decline or improvement in the client's health status, but no less than last five days of every 60 days beginning with the start of care. 1. Patient #3 had a start of care date of 9/12/10. Clinical record revealed an update to the comprehensive assessment for recertification, dated as initiated on12/21/21 but was not electronically signed as completed until 12/26/21, day 2 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, which was 2 days late. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. 2. Patient #5 had a start of care date of 11/6/2019. Clinical record revealed: a. An update to the comprehensive assessment for recertification, dated as initiated on 12/22/21 but was not electronically signed as completed until 12/26/21, day 2 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, which was 2 days late. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode.

G0548

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 3 of 3 sampled patients requiring a resumption of care assessment (Patient #4, #5 and #6). The agency reported completing 5 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: 3. Patient #5 had a start of care date of 11/6/2019. Clinical record review revealed the following a. The clinical note, dated 10/8/2021, documented the hospital contacted the agency on 10/8/2021 to report 3. Patient #5 was being discharged back home. b. The update to the comprehensive assessment at the time of resumption of care, dated 10/9/2021, documented the agency received a verbal resumption of care date on 10/8/2021. The nurse visited the patient on 10/9/2021 to begin collecting resumption of care assessment findings. The nurse did not electronically sign the document as complete until 10/12/2021, 4 days after receiving the resumption of care referral making the assessment 2 days late. The above stated findings were reviewed with the agency Administrator/Clinical Manager and Office Manager. The agency provided no additional information prior to the end of the survey. According to the agency's policy, titled Comprehensive Assessment- Home Health, Therapy and Rehab and dated 2/8/2022, a patient specific comprehensive assessment must be performed within 48 hours of the agency's knowledge of the patient's return home from a hospital inpatient admission for any reason other than diagnostic testing lasting 24 hours or longer or on the physician ordered resumption of care date. According to the agency policy, titled OASIS- Home Health and dated 6/15/2021, the registered nurse must complete the comprehensive assessment within 48 hours of the patient's return home after an inpatient facility discharge or on the physician ordered resumption of care date. 1. Patient #4 had a start of care date of 10/15/2021. Clinical record review revealed the following: a. The resumption of care summary note, dated 1/28/2022, documented Patient #4 was hospitalized for acute hypoxic respiratory failure on 1/20/2022 and returned home on 1/27/2022. b. The update to the comprehensive assessment clinical note, dated 1/28/2022, documented the receiving the resumption of care referral on 1/27/2022. The nurse made the home visit to begin collecting resumption of care assessment findings on 1/28/2021. The nurse did not electronically sign the document as complete until 1/31/2022, 4 days after receiving the resumption of care referral making the assessment 2 days late. c. During agency staff interview on 2/16/2022 at 11:55 AM, the Administrator/Clinical Manager reported she must have forgotten to put some assessment information into the comprehensive assessment, requiring her to reopen the assessment, add the information and electronically sign the document a second time, making the assessment late. 2. Patient #6 had a start of care date of 11/17/2021 and was discharged from agency services on 12/24/2021. Clinical record review revealed the following: a. The clinical note, dated 12/14/2021, documented the hospital contacted the agency on 12/14/2021 to report Patient #6 was being discharged back home. The agency had not been aware the patient was in the hospital. The hospital staff reported the patient was admitted on 12/10/2021 and was currently being discharged. b. The update to the comprehensive assessment at the time of resumption of care, dated 12/16/2021, documented the agency received a verbal resumption of care date on 12/14/2021. The nurse visited the patient on 12/16/2021 to begin collecting resumption of care assessment findings. The nurse did not electronically sign the document as complete until 12/19/2021, 5 days after receiving the resumption of care referral making the assessment 3 days late.

G0572

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care in a timely manner for 4 of 7 sampled patients (Patients #2, #3, #5 and #7). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 2. Patient #2 had a start of care date of 1/3/2022. Clinical record review revealed the following: a. The Plan of Care, dated 1/3/22 to 3/3/22, included physician orders for skilled nursing visits 1 time per week for one week and then 3 times per week to fill med planner biweekly, perform wound care and assess vital signs and all systems, and home health aide visits one time per week for one week and twice weekly for 7 weeks, occupational therapy visits weekly for four weeks beginning 1/10/22 and physical therapy visits twice weekly for 3 weeks, beginning 1/9/22 and then weekly for 4 weeks beginning 2/8/22. b. The occupational therapy visit note, dated 1/19/22, documented the patient refused services due to being ill and not wanting services. c. The physical therapy visit note, dated 1/21/22, documented the patient canceled due to being sick. d. Skilled nursing visit notes, dated 1/31/22 and 2/3/22, documented only two visits were made the week of 1/30/22. The clinical record lacked documentation of physician notification of why the ordered 3rd visit was not made. e. Skilled nursing visit note, dated 2/7/22, documented only one visit was made the week The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 3. Patient #3 had a start of care date of 9/12/18. Clinical record review revealed the following: a. The Plans of Care, dated 10/26/21 to 12/24/21 and 12/25/21 to 2/22/22, included physician orders for skilled nursing visits 1 time per week for assessment to fill med planner and home health aide visits two times per week for 8 weeks. b. The missed visit report, dated 12/21/21, documented the patient cancelled the home health aide visit and did not want to rescheule. The physician was notified on 12/27/21 of the missed visit. The clinical record lacked documentation of why the 2nd visit was not completed the week of 12/19/21 and physician notification of the missed visit. c. The missed visit report, dated 12/28/21, documented the home health aide visit was cancelled due to a staff emergency and the family would provide care. The physician was notified on 12/30/21 of the missed visit. The agency lacked documentation of promptly alerting the physician of the missed visit. d. The missed visit report, dated 12/31/21, documented the home health aide visit was cancelled by the family and did not want to reschedule the visit. The physician was notified on 1/3/22 of the missed visit. The agency lacked documentation of promptly alerting the physician of the missed visit. e. The missed visit report, dated 1/4/22 and 1/7/22, documented the home health aide visit was cancelled by the family and did not want to reschedule the visit. The physician was notified on 1/19/22 of the missed visits. The agency lacked documentation of promptly alerting the physician of the missed visit. f. The missed visit report, dated 1/13/22, documented the home health aide visit was cancelled due to the home health aide being ill and the agency offered another aide and the patient refused. The physician was notified on 1/19/22 of the missed visit. The agency lacked documentation of promptly alerting the physician of the missed visit. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 4. Patient # 5 had a start of care date of 11/6/19. a. The Plan of Care, dated 12/25/21 to 2/22/22, included physician orders for skilled nursing visits 1 time per week and included orders to weight the patient every visit. b. The skilled nurse notes, dated 12/15/21 and 12/29/21, lacked documentation of assessment of the patient's weight. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. The surveyors reviewed the above findings with the agency Administrator/Clinical Manager and the Office Manager. Agency staff provided no additional information prior to then end of the survey. According to the agency policy, titled Plan of Care- Home Health and Therapy and dated 2/8/2022, each clinician should provide service conforming with physician orders. Agency staff should alert the physician with modifications to the Plan of Care if needed. During agency staff interview on 2/15/2022 at 11:11 AM, the Office Manager reported she runs a report of missed visits for nursing and aide services weekly and sends the report to each patient's physician weekly; however, does not have the ability to run a report of missed therapy visits. She reported a plan to contact the therapy office to determine their process for doing this. During agency staff interview on 2/15/2022 at 1:28 PM, the Office Manager reported calling the therapy office to obtain a copy of the missed visit notification. The Office Manager reported she was told the therapy staff document the missed visit in the clinical record and then notify the physician in the discharge summary of any visits missed during the care of the patient. The Office Manager stated "I know this is wrong so we will have to get together with the (therapy) company to work it out." 1. Patient #7 had a start of care date of 12/8/2021 and was discharged from agency services on 1/20/2022. Clinical record review and associated agency staff interviews revealed the following: a. The Plan of Care, dated 12/8/2021 to 2/5/2022, included physician orders for physical therapy visits once daily for 6 weeks beginning 12/12/2021. b. The clinical record lacked documentation of a physical therapy visit during the week of 12/19-25/2021. c. The physical therapy "Quick Note", dated 12/24/2021, documented the therapist was unable to reach the patient to set up a home visit during the week of 12/19-25/2021. d. The discharge summary, dated 1/20/2022 and sent to the physician by facsimile on 1/25/2022, lacked documentation of the missed physical therapy visit. The patient's clinical record lacked documentation of any physician notification of the missed therapy visit for the week of 12/19-25/2021.

G0574

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, home visit observation and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 4 of 7 sampled patients (Patients #1, #2, #3 and #5). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #2 had a start of care date of 1/3/2022. Clinical record review and associated patient interviews revealed the following: a. The Plan of Care, dated 1/3/22 to 3/3/22, included physician orders for glipizide 10 milligrams 9mg) daily for diabetes and Spironolactone 25 mg for diuretic. The narrative note regarding assessment identified the patient's diabetic medication was changed from glipizide to Jardiance and the patient's diuretic was changed from Spironolactone to Bumex. b. The Medication List, dated 2/14/22, documented Jardiance 25 mg was started on 1/3/22. c. A supplement physician order, dated 1/6/22, ordered Bumex 1 mg twice daily. The Plan of Care did not include the current medications used by the patient. d. The Plan of Care, dated 1/3/22 to 3/3/22, identified the following equipment and supplies used to meet the patient's needs: four wheeled walker, manual wheelchair, pill butter, grabber and grab bar in bathroom. During a home visit observation with Staff F, Physical Therapist (PT), the surveyor observed a Lifeline alert button on the patient's four wheeled walker. The patient revealed use of the Lifeline when moved into the assisted living facility last April. e. The Plan of Care lacked identification of the Lifeline alert button as equipment used to meet the patient's needs. During the same home visit, the patient wore gripped gloves to bilateral hands. The patient revealed use of the gloves for 4 to 5 months to aide with obtaining a better grip on the patient's wheelchair. f. The Plan of Care lacked identification of the gripper gloves as equipment used to meet the patient's needs. During the same home visit, the surveyor observed a hospital bed with a side rail in the patient's bedroom. The patient revealed the hospital bed with side rail since moving to the assisted living facility last April. g. The Plan of Care lacked identification of the hospital bed with side rail as equipment used to meet the patient's needs. During the same home visit, the surveyor observed a hand held shower and shower bench in the patient's bathroom. The patient revealed the hand held shower and the shower bench are utilized every time the aide comes for the patient to bathe. Both items have been in the apartment since the patient moved in last April. h. The Plan of Care lacked identification of the hand held shower and bench as equipment used to meet the patient's needs. During the same home visit, the surveyor observed a urinal in the patient's bathroom. The patient revealed use of the urinal since moved into the assisted living facility last April. i. The Plan of Care lacked identification of the urinal as equipment used to meet the patient's needs. During the same home visit, the surveyor observed a reacher in the patient's bedroom next to the bed. The patient revealed use of the reacher for about a year and was given the reacher while residing in the nursing home after hospital stay. j. The Plan of Care lacked identification of the reacher as equipment used to meet the patient's needs. 3. Patient #3 had a start of care date of 9/12/2018. Clinical record review and associated patient interviews revealed the following: a. The Plans of Care, dated 8/27/21 to 10/25/21, 10/26/21 to 12/24/21, and 12/25/21 to 2/22/22, identified the following equipment and supplies used to meet the patient's needs: medication planner, bath bench, cane, walker, and grab bars. During a home visit observation on 2/15/22 at 3:32 PM, with the agency Administrator/Registered Nurse (RN), the surveyor reviewed current supplies in use with the patient . The patient revealed use of incontinence supplies for about 5 years and stated uses full pull ups at times and pads all of the time. b. The Plan of Care lacked identification of incontinence supplies as equipment used to meet the patient's needs. During the same home visit observation with the agency Administrator/Registered Nurse (RN), the surveyor reviewed current supplies in use with the patient . The patient revealed use of a Continuous Positive Airway Pressure (CPAP) machine. The patient revealed has used the CPAP for the past 17 years. c. The Plan of Care lacked identification of the CPAP as equipment used to meet the patient's needs. During the same home visit observation with the agency Administrator/Registered Nurse (RN), the surveyor reviewed current supplies in use with the patient . The patient revealed use of a hand held shower and bench located in the patient's shower. The patient revealed uses every time the home health aide visits to assist with bathing. The patient revealed had both items when lived in the last place, approximately 7-9 years. c. The Plan of Care lacked identification of the hand held shower and bath bench as equipment used to meet the patient's needs. 4. Patient #5 had a start of care date of 11/6/2019. Clinical record review revealed the following: a. The Plans of Care, dated 10/26/21 to 12/24/21and 12/25/21 to 2/22/22, identified the following equipment and supplies used to meet the patient's needs: incontinence products, tub grab bar, lock box for medications. b. Skilled nursing visit notes, dated 1/26/22 and 2/2/22, documented the patient's weight and reported the weight was measured with the patient's scale. c. The Plan of Care lacked identification of the patient's scale as equipment used to meet the patient's needs. The surveyors reviewed the above findings with the agency Administrator/Clinical Manager. Agency staff provided no additional information prior to the end of the survey. 1. Patient #1 had a start of care date of 3/9/2020. Clinical record review, surveyor observation and associated interviews revealed the following: During a home visit to Patient #1's residence while accompanied by Staff A, Registered Nurse, surveyor observation on 2/15/2022 between 11:00 AM and 12:00 Noon, the surveyor observed: a. An electric lift chair located in the patient's main living space. Patient interview during the home visit revealed Patient #1 used the electric lift chair to safely stand and sit in the recliner due to decreased mobility secondary to Parkinson's disease. b. Grab bars in and outside of the shower in the bathroom used by the patient. Patient interview during the home visit revealed Patient #1 had the grab bars installed in the summer of 2021 to assist with safe transfers in and out of the shower. c. Shower bench with a hand held shower system. Patient interview during the home visit revealed Patient #1 sat on the shower bench due to the inability to stand for long periods of time without a walker. The hand held shower system was used to safely bathe independently while seated. d. Scale located in the bathroom. Patient interview during the home visit revealed Patient #1 weighed him/herself daily and kept track of the weights. e. Toilet hand rails in the bathroom. Patient interview during the home visit revealed Patient #1 was unable to sit and stand from the toilet safely, so the rails were obtained in the summer of 2021 to assist with the transfers on and off of the toilet. f. Hospital bed with trapeze (metal triangle hanging from an extension bar over top of the bed) and side rails located in the patient's bedroom. Patient interview during the home visit revealed Patient #1 used the hospital bed to lower and raise for ease and safety getting in and out of bed. The trapeze was used to assist the patient to rise to a seated position and move about in the bed and the side rail to prevent rolling out of bed. The Plans of Care, dated 8/31/2021 to 10/29/2021, 10/30/2021 to 12/28/2021 and 12/29/2021 to 2/26/2022, included the tub bench; however, lacked identification of the patient's use of the hospital bed with trapeze and side rails, scale, toilet hand rails, electric lift chair, grab bars in the shower and the hand held shower system as equipment used by the patient to meet his/her needs.

G0580

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 8 sampled patients (Patient #2). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Plan of Care and dated 2/8/22, all clinical services are implemented in accordance with a Plan of Care and established by physician/non physician written orders. According to the agency policy, titled Wound Care and dated 11/22/21, wound care will be provided according to a providers order. Patient #2 had a start of care date of 1/3/2022. Review of the clinical record and associated agency staff interviews revealed the following: a. The Plan of Care, dated 1/3/22 to 3/3/22, documented surgical wound care orders and simple dressing change of remove gauze dressing, cleanse with water, pat dry, betadine swab, cover with gauze, and apply ACE wrap. b. The skilled nurse visit note, dated 1/7/22, documented the patient had excoriation to right inner buttock and applied Calmoseptine cream for moisture barrier and healing. c. A communication note, dated 1/7/22 and completed by the nurse, documented observation an excoriation to the inner buttock that appeared to be moisture related. Calmoseptine cream was applied for healing and a moisture barrier and the nurse requested an order for Calmoseptine to the affected area twice daily and as needed until healed. d. A communication note, dated 1/7/22 and completed by the nurse, documented the physician did not respond to the order regarding the buttocks and sent a fax for post op wound orders to apply Cadexomer Iodine gel 0.9% topically to the left third toe amputation site and the left lateral ankle daily with the dressing change. e. The skilled nurse visit notes, dated 1/10/22, 1/12/22, 1/17/22, 1/20/22, 1/24/22, documented application of Calmoseptine to right buttock. The nurse continued to perform treatment to the right buttock without a physician's order. f. The aide care plan dated 2/8/22 and 2/11/22, included the nurse's direction to apply calamine lotion to the patient's reddened peri and groin areas. g. The home health aide visit notes, dated 2/8/22 and 2/11/22, documented completion of the task of applying calamine ointment to the patient's reddened peri and groin areas. The clinical record lacked an order for the calamine lotion. Interview on 2/16/22 at 2:00 PM with Staff A, Registered Nurse (RN), reported the nurse never received an order for the Calmoseptine and the RN continued to apply the Calmoseptine. Staff A stated the aide was applying Calazime cream to the patient's buttocks, which is a generic for Calmoseptine. Staff A stated the area is healed and nothing currently applied. The above findings were reviewed with agency Administrator/Clinical Manager. Agency staff provided no further information prior to the end of the survey.

G0706

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 clinical record review, agency policy review, and staff interview, the agency failed to perform ongoing interdisciplinary assessments of the patient for 1 of 1 sampled patients with alteration of skin integrity (Patient #2). The agency reported providing wound care to 3 patients at the time of the survey. Failure to ensure staff obtain physician orders for administration of treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Wound Care, and dated 11/22/21, wounds will be measured in centimeters (length by width by depth) at least weekly unless covered with a non-removable dressing during the skilled nursing visit. Interview with agency Administrator/Clinical Manager on 2/14/2022 at 10:00 AM revealed all wounds are to be measured weekly, including length, width, and depth. Wounds should be care planned for each patient. Patient #2 had a start of care date of 1/3/2022. Clinical record review revealed: a. The Plan of Care dated 1/3/22 to 3/3/221, included orders for skilled nursing visits three times per week and included orders for surgical wound care with instructions to remove the dressing, cleanse with water, pat dry, betadine swab, cover with gauze and then ACE wrap. b. A supplemental order, dated 1/8/22, documented the agency received a fax from the doctor to apply Cadexomer Iodine gel 0.9% topically to the left third toe amputation site and the left lateral ankle daily with the dressing change. c. The initial comprehensive assessment at the time of start of care, dated 1/3/22, documented the patient had 3 incision/wound sites, located on the left outer ankle, left foot 3rd toe amputation site, and left buttock. The nurse documented performance of wound cares to the left outer ankle and left foot 3rd toe amputation site, however, lacked documentation of measurements of the left foot 3rd toe amputation site. The note lacked any wound measurements, including length, width or depth. d. The skilled nursing visit notes, dated 1/7/22, documented the nurse performed wound cares to the left outer ankle and left foot 3rd toe amputation site, however, lacked documentation of measurements of the left foot 3rd toe amputation site. The nurse noted the wound was healing by primary intention. The notes lacked any wound measurements, including length, width or depth for the week of 1/2/22 for the left foot 3rd toe amputation site. e. The skilled nursing visit notes, dated 1/12/22 and 1/14/22, documented the nurse performed wound cares to the left outer ankle and left foot 3rd toe amputation site, however, lacked documentation of measurements the wounds. The nurse noted the left outer ankle wound was not healing and the left foot 3rd toe amputation site was healing by primary intention. The notes lacked any wound measurements, including length, width or depth for the week of 1/9/22. f. The skilled nursing visit notes, dated 1/17/22 and 1/20/22, documented the nurse performed wound cares to the left outer ankle and left foot 3rd toe amputation site, however, lacked documentation of measurements the wounds. The nurse noted the left outer ankle wound was not healing and the left foot 3rd toe amputation site was healing by primary intention. The notes lacked any wound measurements, including length, width or depth for the week of 1/16/22. g. The skilled nursing visit notes, dated 1/24/22, 1/26/22 and 1/27/22, documented the nurse performed wound cares to the left outer ankle and left foot 3rd toe amputation site, however, lacked documentation of measurements the wounds. The nurse noted the left outer ankle wound was not healing and the left foot 3rd toe amputation site was healing by primary intention. The notes lacked any wound measurements, including length, width or depth for the week of 1/23/22. h. The skilled nursing visit note, dated 1/31/22, documented the nurse performed wound cares to the left outer ankle and left foot 3rd toe amputation site, however, lacked documentation of measurements the wounds. The nurse noted the left outer ankle wound was not healing and the left foot 3rd toe amputation site was healing by primary intention. i. The skilled nursing visit note, dated 2/3/22, documented the nurse performed wound cares to the left outer ankle and the left foot 3rd toe amputation site was healed. The assessment of the left outer ankle wound and documented it was not healing. The notes lacked any wound measurements, including length, width or depth for the week of 1/30/22. j. The skilled nursing visit note, dated 2/8/22, documented the nurse performed wound cares to the left outer ankle however, lacked documentation of measurements the wounds. The nurse noted the left outer ankle wound was not healing. The notes lacked any wound measurements, including length, width or depth for the week of 2/6/22. Interview on 2/16/22 with Staff A, Registered Nurse (RN), reported no wound measurements were obtained for the left outer ankle wound and the left foot 3rd toe amputation site as the wounds were chronic and did not ever change in size. The above stated findings were reviewed with the agency Administrator/Clinical Manager and the Office Manager. The agency provided no additional information prior to the end of the survey.

G0768

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on clinical record review, personnel file review and staff interview, the agency failed to: I. ensure home health aides successfully completed all required basic skills competency demonstration while evaluated by a registered nurse observing the task performance prior to providing care to any agency patients for 3 of 4 sampled home health aides (Home Health Aides B, D and E); and II. ensure home health aide successfully completed competency demonstration of any task delegated as an extension of nursing services while evaluated by a registered nurse observing the task performance prior to assigning the aide to provide care to a patient requiring performance of the task(s) for 3 of 3 sampled home health aides (Staff B, C and D), all who provided home health aide services to Patients #2 and #3. The agency identified providing home health aide services to 24 patients at the time of the survey. Failure to ensure home health aides were competent in any assigned skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to the agency policy, titled Home Health Aide Services- Home Health and dated 10/21/2021, the home health aide will be trained and competency tested according to state and federal regulations. According to the agency policy, titled Home Health Aide Supervision and Delegation of Duties and dated 10/21/2021, home health aide services will be under the direction and supervision of a registered nurse when personal cares are indicated. The RN may only delegate tasks to those home health aides deemed competent and possess the knowledge and skills consistent with the complexity of the tasks. During interview on 2/14/2022 at 9:35 AM, the Administrator/Clinical Manager reported competencies for home health aides are kept on a sheet in the personnel files. The registered nurse checks the sheet before assigning an aide to perform a delegated task. If the aide has not been competency tested for that skill, the Administrator/Clinical Manager handles in the office to assure it gets done. I. Basic skills competency Personnel file review revealed the following: 1. Home Health Aide B had a hire date of 12/27/2021. The aide currently provided independent care to agency patients. The Home Health Competency Form documented the registered nurse evaluated the competency of Home Health Aide B by directly observing the aide assess a pseudo-patient's temperature, radial pulse, respirations and blood pressure on 1/13/2022. The Form documented the registered nurse evaluated all other competencies of Home Health Aide B using verbalization by the aide as the method to determine competency. The personnel file lacked documentation of registered nurse observation of the aide performing the tasks of bath in tub, bed, sponge; shower; nail care; assist with dressing and undressing; skin care; oral care; shampoo in sink, tub, bed; toileting assistance; transfer assistance; ambulation assistance; range of motion. 2. Home Health Aide D had a hire date of 12/13/2021. The aide currently provided independent care to agency patients. The Home Health Competency Form documented the registered nurse evaluated the competency of Home Health Aide D by directly observing the aide assess a pseudo-patient's temperature, radial pulse, respirations and blood pressure on 12/23/2022. The Form documented the registered nurse evaluated all other competencies of Home Health Aide D using verbalization by the aide as the method to determine competency. The personnel file lacked documentation of registered nurse observation of the aide performing the tasks of bath in tub, bed, sponge; shower; nail care; assist with dressing and undressing; skin care; oral care; shampoo in sink, tub, bed; toileting assistance; transfer assistance; ambulation assistance; range of motion. 3. Home Health Aide E had a hire date of 2/16/2021. The aide currently provided independent care to agency patients. The Home Health Competency Form documented the registered nurse evaluated the competency of Home Health Aide E by directly observing the aide assess a pseudo-patient's temperature, radial pulse, respirations and blood pressure on 3/1/2021. The Form documented the registered nurse evaluated all other competencies of Home Health Aide E using verbalization by the aide as the method to determine competency. The personnel file lacked documentation of registered nurse observation of the aide performing the tasks of bath in tub, bed, sponge; shower; nail care; assist with dressing and undressing; skin care; oral care; shampoo in sink, tub, bed; toileting assistance; transfer assistance; ambulation assistance; range of motion. The above findings were reviewed with the Administrator/Clinical Manager and the Office Manager. The Administrator/Clinical Manager believed that the aides had been competency tested for basic skills using direct observation when the aide was performing the tasks on a pseudo patient and had no idea why the registered nurse had documented the mode of competency determination was by the aide verbalization. No further information was provided prior to the end of the survey. II. Skills delegated as an extension of nursing services Clinical record review and personnel file review revealed the following: 1. Patient #2 had a start of care date of 1/3/2022. Clinical record review revealed the nurse assigned the home health aide to apply medicated ointment to patient's groin, perform a simple dressing change to the patient's left ankle and apply the ace wrap to the patient's left ankle. The clinical record included visit documentation signed by Home Health Aides B, C and D. Personnel file review revealed the following: a. Home Health Aide B had a hire date of 12/27/2021. The aide's personnel file lacked documentation of registered nurse observation of the aide performing the tasks of application of topical medications, simple dressing changes and ace wrap application. Home Health Aide B was assigned to care for Patient #2. Patient #2 required the application of topical medications, simple dressing changes and ace wrap application. The aide was not deemed competent on any of the three tasks before being assigned to care for Patient #2. b. Home Health Aide C had a hire date of 7/22/2019. The aide's personnel file lacked documentation of registered nurse observation of the aide performing the tasks of application of topical medications and ace wrap application. Home Health Aide C was assigned to care for Patient #2. Patient #2 required the application of topical medications and ace wrap application. The aide was not deemed competent on either task before being assigned to care for Patient #2. c. Home Health Aide D had a hire date of 12/23/2021. The aide's personnel file lacked documentation of registered nurse observation of the aide performing the tasks of application of topical medications, simple dressing changes and ace wrap application. Home Health Aide D was assigned to care for Patient #2. Patient #2 required the application of topical medications, simple dressing changes and ace wrap application. The aide was not deemed competent on any of the three tasks before being assigned to care for Patient #2. 2. Patient #3 had a start of care date of 9/12/2018. Clinical record review revealed the nurse assigned the home health aide to apply medicated powder under the breast and abdominal folds; apply a medicated gel to the shoulder/back region; and shave the patient. The clinical record included visit documentation signed by Home Health Aides B, C and D. Personnel file review revealed the following: a. Home Health Aide B had a hire date of 12/27/2021. The aide's personnel file lacked documentation of registered nurse observation of the aide performing the tasks of application of topical medications and shaving. Home Health Aide B was assigned to care for Patient #3. Patient #3 required the application of topical medications and shaving. The aide was not deemed competent on either of the tasks before being assigned to care for Patient #3. b. Home Health Aide C had a hire date of 7/11/2019. The aide's personnel file lacked documentation of registered nurse observation of the aide performing the tasks of application of topical medications. Home Health Aide C was assigned to care for Patient #3. Patient #3 required the application of topical medications. The aide was not deemed competent to perform the task before being assigned to care for Patient #3. c. Home Health Aide D had a hire date of 12/23/2021. The aide's personnel file lacked documentation of registered nurse observation of the aide performing the tasks of application of topical medications and shaving. Home Health Aide D was assigned to care for Patient #3. Patient #3 required the application of topical medications and shaving. The aide was not deemed competent on either of the tasks before being assigned to care for Patient #3. The above findings were reviewed with the Administrator/Clinical Manager and the Office Manager. No further information was provided prior to the end of the survey.

G0798

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 clinical record review and agency policy review, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 3 sampled patients receiving home health aide services (Patients #2, and #3). The agency reported 24 patients who received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: According to agency policy, titled Home Health Aide Supervision and Delegation of Duties dated 10/21/21, the case manager or designated Registered Nurse will develop the written home health aide care plan for the patient. 1. Patient #2 had a start of date of 1/3/22 and received three times per week skilled nursing services and two times per week home health aide services from the agency. The Plan of Care, dated 1/3/22 to 3/3/22, documented a diagnosis of type 2 diabetes mellitus with chronic skin ulcer. The initial comprehensive assessments, dated 1/3/22, documented the patient required presence of another with bathing. Clinical record review revealed: The home health aide assignments for the months of October, November, and December directed the aides to perform the task of bath, shampoo 1-2 times per week as requested, perform skin care, and foot care (but no nail trim), and apply antifungal cream to rash areas under the breasts and abdominal folds as requested. b. The RN assigned task to the aide of simple dressing change with instructions to remove the gauze dressing, cleanse with water, pat dry, apply betadine, cover with bandaid, cover with gauze, and apply ACE wrap, but did not identify the specific location of where the simple dressing change was to be completed by the aide. The aide assignment was not specific and individualized to meet the needs of Patient #2. 2. Patient #3 had a start of care date of 9/12/18 and received weekly skilled nursing services and two times per week home health aide services from the agency. The Plans of Care, dated 10/26/21 to 12/24/21 and 12/25/21 to 2/2/22, documented a diagnosis of hypertensive heart disease with chronic kidney disease. The recertification comprehensive assessments, dated 10/22/21 and 12/21/21, documented the patient was able to bathe in the shower or tub with intermittent assistance of another person for intermittent supervision or encouragement or reminders or to get in and out of the shower or tub or for assistance washing difficult to reach areas. Clinical record review revealed: a. The home health aide assignments for the months of December, January, and February, included direction to the aide to assist with Activities of Daily Living (ADLs), and Instrumental Activities of Daily Living (IADLs), shower every visit and wash hair and back for the patient, shave and shampoo and brush hair after shampoo, perform skin care apply powder to abdominal folds, under breasts, armpits, groin, and belly button, assist with biofreeze to lower back, between shoulders and right arm, lotion after bath , assist with dressing, undressing after bath, and assist with ambulation with standby assistance. b. The RN assigned task to the aide of shave and shampoo and brush hair after shampoo was to be completed by the aide. The aide assignment included multiple unrelated tasks that were not specific and individualized to meet the needs of Patient #3. c. The RN assigned task to the aide of perform skin care apply powder to abdominal folds, under breasts, armpits, groin, and belly button, assist with biofreeze to lower back, between shoulders and right arm, lotion after bath to be completed by the aide. The aide assignment included multiple tasks that were not specific and individualized to meet the needs of Patient #3. The above findings were reviewed with the agency Administrator/Clinical Manager and Office Manager. The agency provided no additional information prior to the end of the survey.

G0800

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services (Patient #3). The agency reported providing home health aide services to 24 patients at the time of the survey. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to the undated agency policy, titled Assignment and Supervision of the Home Care Aide, the home care aide is assigned by the scheduler and follows written instructions which are reviewed according to appropriate regulations and guidelines. According to the undated agency policy, titled Home Care Aide Duties, general duties include personal hygiene, body positioning/services, measurements, assistance with health care needs (including application of bandages to superficial abrasions/lacerations), emergency measures, preventative applications (including application of protective skin barriers on intact skin (transparent dressing such as Tegaderm or Opsite hydrocolloid such as Duoderm or Replicare). Home Care Aides do not perform and are not assigned by the Registered Nurse to apply debriding ointments and perform dressing changes to wounds beyond a superficial depth. Patient #3 had a start of care date of 9/12/2018. The Plans of Care, dated 10/26/21 to 12/24/21 and 12/25/21 to 2/22/22, included physician orders for skilled nursing services for assessment and medication set up weekly and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan for the months of December, January and February, included direction to the aide to assist with Activities of Daily Living (ADLs), and Instrumental Activities of Daily Living (IADLs), shower every visit and wash hair and back for the patient, shave and shampoo and brush hair after shampoo, perform skin care apply powder to abdominal folds, under breasts, armpits, groin, and belly button, assist with biofreeze to lower back, between shoulders and right arm, lotion after bath , assist with dressing, undressing after bath, and assist with ambulation with standby assistance. b. Home health aide visit notes, dated 12/17/21, 1/11/22, 1/18/22, 1/25/22, and 2/1/22, documented completion of the task of shaving/shampooing hair and brushing hair after shampoo. During home visit observation on 2/15/22 at 3:32 PM, with the Administrator/Registered Nurse (RN), the RN reviewed the aide care plan with the patient. The patient reported the home health aide does not perform shaving for the patient and he/she is independent with shaving. The home health aide visit notes failed to include documentation the aide did not perform the task of shaving and failed to document why the task was not performed. c. The Plans of Care, dated 10/26/21 to 12/24/21 and 12/25/21 to 2/22/22, lacked inclusion of the extra skills of application of nystatin powder to abdominal folds, under breasts, armpits, groin, and belly button and assisting with biofreeze to lower back, between shoulder and right arm, tasks which are an extension beyond the basic skills of home health aide training and require physician approval. The home health aide failed to provide services that are ordered by the physician, included in the plan of care and consistent with home health aide training. The above findings were reviewed with the agency Administrator/Clinical Manager and Office Manager. Agency staff did not provide any further information prior to the end of the survey.

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