Every finding on record at Grant Memorial Homecare and Hospice, LLC

An emergency preparedness survey was conducted at Grant Memorial Homecare from 05/17/21 to 05/19/21. The facility was found to be in compliance with the Emergency Preparedness Conditions of Participation for Home Health Agencies.

A recertification survey was conducted at Grant Memorial Homecare from 05/17/21 to 05/19/21. A Focused Coronavirus Disease-19 (COVID-19) survey was conducted during the same survey period. The facility provides skilled nursing, physical therapy, occupational therapy, master social work and home health aide services to Grant, Hardy and Pendleton counties. The active census was one hundred forty-four (144). The unduplicated census for the past twelve (12) months was two hundred forty-nine (249). Seven (7) clinical records were reviewed. Three (3) home visits were conducted. Two (2) Condition level deficiencies were cited at G 510, with a related standard level deficiency cited at G 530, and G 1008, with a related standard level deficiency cited at G 1024. A standard level deficiency unrelated to any Conditions was cited at G 604. As a result of the cited Condition level deficiencies, this agency will not be permitted to complete home health aide training or competency evaluations for two (2) years as per regulation 42 CFR 484.80(f)(3). A. An Immediate Jeopardy (IJ) to Comprehensive Assessment of Patients was called on 05/18/21 at 12:27 PM for failure to include Advance Directives as part of the comprehensive assessment. B. Serious injury, serious harm, serious impairment or death: Patient #1's Advance Directives (which included Do Not Resuscitate {DNR}, Living Will and Medical Power of Attorney were not included in her comprehensive assessment. This created the potential for serious harm or injury occurring to Patient #1 from cardiopulmonary resuscitation. This places all patients at risk for serious harm or injury as a result of Advance Directives not being assessed. C. Need for immediate action: Immediate Action needs to be taken to prevent serious harm or injury to patients who have directives for DNR. D. An immediate remedial plan of correction was received by the State Agency Program Manager. It was accepted and the facility abated the IJ on 05/18/21 at 4:18 PM.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review, observation, staff interview and document review it was determined the facility failed to perform a patient-specific comprehensive assessment for one (1) out of seven (7) patients by not including Advanced Directives (Patient #1). This resulted in the potential for serious harm or injury to Patient #1 inflicted during unwanted cardiopulmonary resuscitation. This failure creates the potential for serious harm or injury to all patients. (See Tag G 530). A. An Immediate Jeopardy (IJ) to Comprehensive Assessment of Patients was called on 05/18/21 at 12:27 PM for failure to include Advance Directives as part of the comprehensive assessment. B. Serious injury, serious harm, serious impairment or death: Patient #1's Advance Directives (which included Do Not Resuscitate {DNR}, Living Will and Medical Power of Attorney were not included in her comprehensive assessment. This created the potential for serious harm or injury occurring to Patient #1 from cardiopulmonary resuscitation. This places all patients at risk for serious harm or injury as a result of Advance Directives not being assessed. C. Need for immediate action: Immediate Action needs to be taken to prevent serious harm or injury to patients who have directives for DNR. D. An immediate remedial plan of correction was received by the State Agency Program Manager. It was accepted and the facility abated the IJ on 05/18/21 at 4:18 PM.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review, observation, staff interview and document review it was determined the facility failed to ensure comprehensive assessments were complete. The facility did not include Advance Directives in the assessment for one (1) out of seven (7) patients (Patient #1). This failure creates the potential for serious harm or injury to all patients. Findings include: 1. A review of Patient #1's clinical record revealed the start of care comprehensive assessment (OASIS), completed 5/5/21, did not include that Patient #1 had a living will or a Medical Power of Attorney (MPOA). The OASIS did not include her wishes for Cardiopulmonary Resuscitation (CPR) to be withheld in the event of a cardiopulmonary arrest. The facility did not include those wishes, the Living Will or the MPOA in the Plan of Care. Patient #1's neurological status as documented in the comprehensive OASIS assessment was listed as alert, oriented and forgetful. A determination she lacked capacity was not in the clinical record. 2. Observations conducted 05/18/21 at 9:00 AM during an Occupational Therapy (OT) visit at Patient #1's home revealed a blank form titled "Advance Directives" was located in Patient #1's medical journal. 3. An interview was conducted with the OT on 05/18/21 at 8:45 AM, immediately prior to a home visit with Patient #1. She stated she was a full code. She had a living will but it wasn't in the clinical record. There was a form kept in each patients' home in their medical journal to document attempts to obtain copies of their living will and MPOA. Once the form was completed, after three (3) consecutive home health visits, the form would be returned to the office and scanned into the patient's record. 4. An interview was conducted with Patient #1 on 05/18/21 at 8:50 AM. She stated she has a living will but is unsure what it contains. Her daughter, who is her MPOA, has the living will. She did not want CPR (in the event of a cardiopulmonary arrest). 5. An interview was conducted with the Executive Director on 05/18/21 at 11:20 AM. She concurred the facility failed to follow their procedure for obtaining and documenting Patient #1's Advance Directives. She concurred performing CPR on a patient who wanted it withheld would result in serious harm or injury to the patient. 6. A phone interview was conducted with Patient #1's daughter on 05/18/21 at 5:20 PM. She stated she was Patient #1's MPOA and Durable Power of Attorney. She stated her mother has a living will but she doesn't know where it is. While her mother was in the hospital with her broken hip (just prior to this Home Health episode) she choked and was given the Heimlich maneuver. This broke two (2) ribs. After that her mother said, "No CPR". She thinks her mother understands her body is 'just falling apart' and her mother realizes, though she is confused at times, that if she is resuscitated it would 'damage her beyond repair'. She agrees with her mother's decision to have CPR withheld in the event of a cardiopulmonary arrest. 7. A review of a document titled "Advance Directives," revised 01/01/19, revealed in part: "The agency will attempt to obtain copies of the patient's Advance Directives...On admission, the patient or designated decision maker makes known the patient's wishes regarding Advance Directives. This is documented within the electronic medical record...The qualified clinician will document in the medical record whether the patient has completed Advance Directives, whether a copy of the Advance Directives have been obtained...Advance Directives are reviewed within the medical record." 8. An interview was conducted on 05/18/21 at 12:10 PM with the Patient Care Manager. She stated the Advance Directive form for Patient #1 was complete and ready to be scanned into her clinical record. The form was marked Patient #1 had an MPOA and a living will. She acknowledged the form had been completed and submitted to the office after the home visit with the surveyor occurred.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on staff interview and document review it was determined the facility failed to integrate orders from patients' specialized physicians into the Plan of Care. This failure creates the potential for harm to all patients from uncoordinated care. Findings include: 1. An entrance interview was conducted on 05/17/21 at 10:25 AM with the Executive Director (ED), the Patient Care Manager (PCM) the Business Manager and (by phone) the Performance Improvement Coordinator (PIC). The ED and PCM stated when patients see consulting physicians or physicians who specialize and have new orders from them, the nurse notifies the Primary Care Physician. The PCM and ED stated they used to include verbiage in the patients' orders that orders could be taken from a consulting physician or specialist. They stated they removed that verbiage. The PIC stated there had been a computer software update in March 2021 and they should be including verbiage to accept orders on the Plan of Care. She asked the PCM and ED, "Aren't you including that?" They responded, "No." 2. Review of document titled "Chapter: Provision of Care, Treatment and Services," revised 02/01/20, revealed in part: "No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician, or as designated by State Practice Act and that order be reduced to writing and signed/dated by the ordering physician."

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, record review, staff interview and document review it was determined the facility failed to ensure clinical records were complete. The facility did not include current Advance Directives for one (1) out of seven (7) patients (Patient #1). This failure creates the potential for serious harm or injury to all patients (See Tag G 1024).

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 record review, observation, staff interview and document review it was determined the facility failed to ensure clinical records were complete and accurate with a current Advanced Directive in one (1) of seven (7) patients (Patient #1). This failure has the potential to cause serious harm or death to all patients who request an Advanced Directive. Findings include: 1. A review of Patient #1's clinical record revealed the start of care comprehensive assessment (OASIS), completed 5/5/21, did not include information that Patient #1 had a living will or a Medical Power of Attorney (MPOA). The OASIS did not include her wishes to have Cardiopulmonary Resuscitation (CPR) withheld in the event of a cardiopulmonary arrest. In addition, the facility did not include those wishes, the Living Will or the MPOA in the Plan of Care. Patient #1's neurological status in the OASIS assessment was listed as alert, oriented and forgetful. A determination she lacked capacity was not in the clinical record. 2. Observations conducted on 05/18/21 at 9:00 AM during an Occupational Therapy (OT) visit at Patient #1's home revealed a blank form titled "Advance Directives" was located in her medical journal. 3. An interview was conducted with the OT on 05/18/21 at 8:45 AM, immediately prior to a home visit with Patient #1. She stated Patient #1 was a "full code" and had a living will but it wasn't in the clinical record. She stated there was a form kept in each patients' home in their medical journal to document attempts to obtain copies of their living will and MPOA. She stated once the form was completed, after three (3) consecutive home health visits, the form would be returned to the office and scanned into the patient's record. 4. An interview was conducted with Patient #1 on 05/18/21 at 8:50 AM. She stated she has a living will but is unsure what it contains. She stated her daughter, who is her MPOA, has the living will. She stated she did not want CPR. 5. An interview was conducted with the Executive Director on 05/18/21 at 11:20 AM. She concurred the facility failed to follow their procedure for obtaining and documenting Patient #1's Advance Directive. She concurred performing CPR on a patient who wanted it withheld would result in serious harm or injury to the patient. 6. A phone interview was conducted with Patient #1's daughter on 05/18/21 at 5:20 PM. She stated she is Patient #1's MPOA and Durable Power of Attorney. She stated her mother has a living will but she doesn't know where it is. She stated while her mother was in the hospital with her broken hip (just prior to this Home Health episode) she choked and was given the Heimlich maneuver, resulting in two (2) broken ribs. After that her mother said, "No CPR." She stated she thinks her mother understands her body is 'just falling apart' and her mother realizes, though she is confused at times, that if she is resuscitated it would 'damage her beyond repair'. The MPOA stated she agrees with her mother's decision to not be resuscitated. 7. A review of a document titled "Advance Directives," revised 01/01/19, revealed in part: "The agency will attempt to obtain copies of the patient's Advance Directives...On admission, the patient or designated decision maker makes known the patient's wishes regarding Advance Directives. This is documented within the electronic medical record...The qualified clinician will document in the medical record whether the patient has completed Advance Directives, whether a copy of the Advance Directives have been obtained...Advance Directives are reviewed within the medical record." 8. An interview was conducted 05/18/21 at 12:10 PM with the Patient Care Manager. She stated the Advanced Directive form for Patient #1 was complete and ready to be scanned into her clinical record. The form was marked Patient #1 had an MPOA and a living will. She acknowledged the form had been completed and submitted to the office after the home visit with the surveyor occurred.