Every finding on record at Good Samaritan Society Home Health

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Good Samaritan Society Home Health, Home Health Agency (HHA) on 08/06/2021 found that your facility was in substantial compliance with the participation requirements under 42 CFR 484.102.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Good Samaritan Society Home Health, Home Health Agency (HHA) on 08/06/2021 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

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 interview and record reviews, the facility failed to provide a plan of care that identifies patient-specific measurable outcomes and goals for 12 (P (patient) 1, P2, P3, P4, P5,P6, P7, P9, P12, P14, P16, P17) out of 17 (P1 through P17) patient charts sampled. This deficient practice is likely to increase the likelihood of patients receiving care that is not specific, measurable, and does not meet their treatment needs. The findings are: A. Record review of P1's "Home Health Certification and Plan of Care" from 06/26/2020 revealed: 1. Patient care goal of: "Patient/caregiver will verbalize understanding of when to contact agency if patient having questions or condition changes." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient/caregiver will verbalize understanding of compliance with medications and treatments to avoid hospitalization." No specific definition of timeframe for goal to be achieved by. 3. Patient care goal of "Patient/caregiver verbalize understanding of medication regimen." No specific definition of timeframe for goal to be achieved by. 4. Patient care goal of "Patient returns to normal urinary baseline and free of infection." No specific definition of "urinary baseline." 5. Patient care goal of "Patient will identify strengths and care preferences." No specific definition of timeframe for goal to be achieved by. B. Record review of P2's "Home Health Certification and Plan of Care" from 06/01/2021 revealed: 1. Patient care goal of: "Patient/caregiver will verbalize understanding of when to contact agency if patient having questions or condition changes." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient/caregiver will verbalize understanding of compliance with medications and treatments to avoid hospitalization." No specific definition of timeframe for goal to be achieved by. C. Record review of P3's "Home Health Certification and Plan of Care" from 09/02/2020 revealed: 1. Patient care goal of: "Patient demonstrates increased activity/endurance reaching optimal level of function" No definition of "optimal level of function." 2. Patient care goal of: "Patient/caregiver demonstrates progressive independence in ..." Goal is incomplete. 3. Patient care goal of: "Patient/caregiver demonstrates safe transfer techniques." No specific definition of timeframe for goal to be achieved by. 4. Patient care goal of: "Patient/caregiver will verbalize understanding of when to contact agency if patient having questions or condition changes." No specific definition of timeframe for goal to be achieved by. 5. Patient care goal of: "Patient/caregiver will verbalize understanding of compliance with medications and treatments to avoid hospitalization." No specific definition of timeframe for goal to be achieved by. D. Record review of P4's "Home Health Certification and Plan of Care" from 07/23/2020 revealed: 1. Patient care goal of: "Patient/caregiver will verbalize understanding of when to contact agency if patient having questions or condition changes." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient's functional status is at maximum level within disease limits." No definition of "functional status". 3. Patient care goal of: "Patient demonstrates safe, effective swallowing methods." No specific definition of timeframe for goal to be achieved by. E. Record review of P5's "Home Health Certification and Plan of Care" from 05/02/2021 revealed: 1. Patient care goal of: "Patient will identify strengths and care preferences." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient demonstrates increased activity/endurance reaching optimal level of function" No definition of "optimal level of function." 3. Patient care goal of: "Patient/caregiver verbalizes/demonstrates understanding of pain management." No specific definition of timeframe for goal to be achieved by. F. Record Review of P6's "Home Health Certification and Plan of Care" from 04/06/2021 revealed: 1. Patient care goal of: "Patient/caregiver demonstrates knowledge of med (medication) dose, frequency, actions, side effects, and interactions." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient will identify strengths and care preferences." No specific definition of timeframe for goal to be achieved by. 3. Patient care goal of: "Patient demonstrates increased activity/endurance reaching optimal level of function" No definition of "optimal level of function." 4. Patient care goal of: "Patient/caregiver verbalizes/demonstrates understanding of pain management." No specific definition of timeframe for goal to be achieved by. G. Record review of P7's "Home Health Certification and Plan of Care" from 06/04/2021 revealed: 1. Patient care goal of: "Patient's functional status is at maximum level within disease limits." No definition of specific "maximum level". 2. Patient care goal of: "Patient seizure activity will be controlled within the limits of disease process." No definition of "limits of disease process." H. Record review of P9's "Home Health Certification and Plan of Care" from 06/25/2021 revealed: 1. Patient care goal of: "Patient/caregiver demonstrates compliance with catheter care." No specific definition of timeframe for goal to be achieved by. I. Record review of P12's "Home Health Certification and Plan of Care" from 05/06/2021 revealed: 1. Patient care goal of: "Patient will identify strengths and care preferences" No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient/caregiver demonstrates understanding of cardiac (heart related) disease/care, treatment goals and self-care management." No specific definition of timeframe for goal to be achieved by. 3. Patient care goal of: "Patient maintains stable cardiovascular (heart and circulation related) status at baseline within patient parameters" No definition of "baseline within patient parameters." 4. Patient care goal of: "Patient/caregiver verbalizes how to contact agency and/or EMS (emergency medical system) in the event of an emergency." No specific definition of timeframe for goal to be achieved by. J. Record review of P14's "Home Health Certification and Plan of Care" from 06/08/2021 revealed: 1. Patient care goal of: "Patient will identify strengths and care preferences." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient/caregiver demonstrates compliance with catheter (foley catheter, device used to drain urine from the bladder) care." No specific definition of timeframe for goal to be achieved by. 3. Patient care goal of: "Patient/caregiver will verbalize signs/symptoms to report to RN (registered nurse)/MD (medical doctor)." No specific definition of timeframe for goal to be achieved by. 4. Patient care goal of: "Patient will ambulate (walk) length of apartment hallway two times consecutively." No specific definition of timeframe for goal to be achieved by. K. Record review of P16's "Home Health Certification and Plan of Care" from 04/01/2021 revealed: 1. Patient care goal of: "Patient/caregiver verbalizes/demonstrates knowledge of wound treatment plan by- educated [P16] to follow up with wound care due to poor healing with current treatment." No specific definition of timeframe for goal to be achieved by. L. Record review of P17's "Home Health Certification and Plan of Care" from 07/04/2021 revealed: 1. Patient care goal of: "Patient/caregiver verbalizes understanding of IV (intravenous, fluid or medications administered into the vein or veins) therapy and signs/symptoms to report to RN/MD." No specific definition of timeframe for goal to be achieved by. 2. Patient care goal of: "Patient verbalizes return to their acceptable comfort/pain level." No specific definition of "acceptable comfort/pain level." M. On 08/04/2021 at 2:00 pm, interview with S (staff) 1 (Administrator), reported that the expectation regarding plan of care goals includes time frames and patient specific definitions in order to make the goals achievable and measurable. N. Record review of facility's curriculum on therapy goals given on 07/21/2021 revealed: 1. "Therapy should establish short and long term measurable therapy goals and the goals must contain an objectively measurable component with an achievement timeframe/date for each goal." O. Record review of facility's "Home health training on care plans" for nursing held on 08/04/2021 revealed: "Goal [plan of care goals] need to have an attainable time frame."

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based record reviews and interviews the facility failed to record advance directives (information on critical emergent treatment that patient would want if they were unable to make their needs known) for 3 (P (patient) 2, P11, & P14) out of 17 (P1 through 17) patient charts sampled. This deficient practice is likely to lead to absence of vitally needed patient information regarding advanced directives, should the patient be in a critical situation where they are unable to make their wishes known. The findings are: A. Record review of P2's medical record form 04/02/2021 revealed: 1. Documentation in Home Health Certification and Plan of Care indicating that P2 is listed as a Do Not Resuscitate (DNR, instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating). 2. Original document dictating P2's DNR was not found in the medical record 3. No "Resuscitation Status Form" to denote if they refused to provide a copy of their advanced directives found in the medical record. B. Record review of P11's medical record from 06/18/2021 revealed: 1. Documentation in Home Health Certification and Plan of Care indicating that P11 is listed as a Do Not Resuscitate . 2. Original document dictating P11's DNR was not found in the medical record. 3. No "Resuscitation Status Form" to denote if they refused to provide a copy of their advanced directives found in the medical record. C. Record review of P14's medical record from 06/08/2021 revealed: 1. Documentation in Home Health Certification and Plan of Care indicating that P14 is listed as a Do Not Resuscitate 2 . Original document dictating 14's DNR was not found in the medical record. 3. No "Resuscitation Status Form" to denote if they refused to provide a copy of their advanced directives. D. On 08/05/2021 at 1:00 pm, interview with S (staff) 2 (Director) reported that the expected process is for patients to fill out a "Resuscitation Status Form" that indicates what advanced directives they have and if they wish to provide a copy to the facility. S2 confirmed that P2, P11, and P14 did not have a filled out "Resuscitation Status Form" to denote if they refused to provide a copy of their advanced directives.