Every finding on record at Great Plains Healthcare, Inc.

The complaint investigation #71668-C conducted by the Department of Inspections and Appeals from 9/6/22 through 9/8/22, was substanstiated with related standard level deficiencies under the Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patients. The survey found the agency in substantial compliance with the Condition of Partcipation 42 CFR 484.50 Patient's Rights. The agency reported a current census of 2 patients at the time of the survey.

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 update to the comprehensive assessment at the time of discharge for 5 of 5 sampled patients with discharges (Patient #3, #4, #5, #6 and #7). Failure to ensure medications were reviewed at the time of discharge with a current and accurate drug regimen review and failure to identify acutual/potential concerns, increased the potential for unidentified medication interactions and side effect risks to the patient at the time of discharge. Findings include: According to agency policy, titled Medication Profile and dated 4/5/2022, the drug regimen review will be performed at the time of admission and when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. Interview on 9/8/22 at 11:14 AM with Staff D, Registered Nurse, reported Drug Regimen Review (DRR) is completed with each comprehensive assessment. The DRR button does not come up at regular visits and is only part of the electronic health record (EHR) for comprehensive assessments. The nurse could not remember if it comes up for discharge. 1. Patient #3 had a start of care date of 6/27/22 and was discharged from the agency on 8/25/22. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 8/25/22, lacked any documentation of a completed drug regimen review. b. The Client Medication Report located in the patient's electronic clinical record lacked documentation of a completed drug regimen review completed by a registered nurse (RN) after 6/27/22. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 2. Patient #4 had a start of care date of 6/23/22 and was discharged from the agency on 8/18/22. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 8/18/22, lacked any documentation of a completed drug regimen review. b. The Client Medication Report, located in the patient's electronic record, lacked documentation of a completed drug regimen review by a RN after 7/22/22. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 3. Patient #5 had a start of care date of 7/18/22 and was discharged from the agency on 8/24/22. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 8/24/22, lacked any documentation of a completed drug regimen review. b. The Client Medication Report, located in the patient's electronic record, lacked documentation of a completed drug regimen review by a RN after 8/16/22. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 4. Patient #6 had a start of care date of 7/11/22 and was discharged from the agency on 7/14/22. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 7/14/22, lacked any documentation of a completed drug regimen review. b. The Client Medication Report, located in the patient's electronic record, lacked documentation of a completed drug regimen review by a RN after 7/12/22. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 5. Patient #7 had a start of care date of 6/2/22 and was discharged from the agency on 6/28/22. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of discharge, dated 6/28/22, lacked any documentation of a completed drug regimen review. b. The Client Medication Report, located in the patient's electronic record, lacked documentation of a completed drug regimen review by a RN after 6/6/22. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. The above findings were reviewed with the agency Administrator, the Administrator in training, and Staff D, Registered Nurse. Agency staff provided no additional information prior to the end of the survey.

The recertification survey, conducted from 4/11/2022 through 4/13/2022, identified the following deficiencies related to emergency preparedness.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and all associated emergency preparedness policies, the agency failed to ensure the development of a policy and procedures to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the emergency preparedness plan and all associated policies, dated 4/2018 and reviewed/updated 8/31/2021, revealed a lack of policy and planned procedure for notification of appropriate state and local emergency officials of homebound patients in need of evacuation due to disaster or emergency situations as required by regulation. The findings were reviewed with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a written policy and planned procedures to locate on-duty staff and patients in the event of an emergency or disaster and inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of service. Failure to have procedures in place for to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's emergency preparedness plan and associated agency policies, dated April 2018 and updated 8/31/2021, revealed the agency failed to outline the procedure to follow to follow up with on-duty staff and patients to determine services that are needed in the event of an interruption in service due to an emergency or disaster, including timeframes for check-in, a process for reporting any unaccounted for on-duty staff or patients to local and state emergency officials and a contingency staffing plan to address unaccounted staff as required by regulation. The findings were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and related policies, the agency failed to have a written policy and procedure for the integration of volunteers, including state and federally designated health care professionals, to coordinate and identify the potential roles to address surge needs during a disaster or emergency. Failure to ensure the home health agency developed policies and procedures to address the use of volunteers or other emergency staffing strategies during an emergency, placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include: The agency's emergency plan and associated policies, dated 4/2018 and reviewed/updated 8/31/2021, lacked a process for the integration of volunteers, including State and Federally designated health care professionals, to address surge needs during an emergency as required by regulation. The findings were reviewed with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan, the agency failed to maintain contact information for Federal, State, regional and local emergency officials. Failure to maintain contact information for Federal, State, regional and local emergency officials placed patients and on-duty staff at risk for delay in needed assistance during a disaster or emergency. Findings include: The agency's emergency preparedness plan and associated policies, dated 4/2018 and reviewed/updated 8/31/2021, failed to maintain contact information for Federal, State, regional and local emergency preparedness officials either in writing or electronically stored as required by regulation. The findings were reviewed with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan/policies, review of agency emergency preparedness training and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 4 of 7 sampled employees, (Staff B, Staff D, Staff F and Staff G). Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: Review of the agency's emergency preparedness plan and associated policies, dated 4/2018 and reviewed/updated 8/31/2021, revealed each staff must receive initial training in emergency preparedness policies and procedures related to their assigned emergency response roles and biannually thereafter. On 4/13/22 at 10:00 AM the surveyor requested documentation of Emergency Preparedness training provided to the Clinical Manager, Staff B, Registered Nurse (RN), Staff D, RN, Staff F, Certified Nursing Assistant (CNA), Staff G, CNA, Staff H, RN, and Staff I, RN. During agency staff interview, on 4/13/2022 at 10:00 AM, Staff F, Administration Assistant reported she cannot find documentation of the training for Staff B, RN, Staff D, RN, Staff F, CNA or Staff G, CNA, as requested. The agency failed to ensure all staff completed initial and biannual training in emergency preparedness as required by regulation. The above stated findings were reviewed with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.

A recertification survey was conducted by the Department of Inspections and Appeals from 4/11/2022 through 4/13/2022. The recertification survey found the agency was operating out of compliance with the following Conditions of Participation: 1) Condition of Participation 42 CFR 484.50 Patient Rights (G406, G440, G462, G464, G466, G468, and G470) and 2) Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patients (G510, G536, G546, G548, and G550). As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 4/13/22 and ending on 4/13/24. The survey also found the agency operating out of compliance with multiple other standard level regulatory requirements. The agency reported a current census of 0 patients due to recently expanding geographic service area and changing location of office from Cherokee, Iowa to Clarion, Iowa.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, review of additional applicable documents, agency staff interview and patient interview, the agency failed to do the following: 1) ensure patients were advised verbally and in writing of the extent to which payment for services may be expected (G440); 2) ensure agency staff determined discharge for cause that meets the requirements that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent delivery of care to the patient or ability of the agency to operate is seriously impaired (G462); 3) ensure agency staff advised the patient and physician the agency was considering cause for discharge (G464); 4) ensure agency staff made efforts to resolve the problem before discharging (G466); and 5) ensure agency staff provided contact information for other resources and providers at discharge for cause (G468) and 6) ensure agency staff documented the problem and efforts made to resolve the problem and enter this documentation into its clinical records (G470). The systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's patients.

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, the agency failed to ensure agency staff advised the patient or the patient's representative, both verbally and in writing, the extent to which payment for agency services may be expected, 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/or the charges the individual may have to pay out of pocket for services prior to initiation of care for 7 of 7 sampled patients with start of care since the last recertification survey (Patients #1, #2, #3, #4, #8, #9, and #10). 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 violated patients' rights and increased the risk the patient may be billed for unexpected charges. Findings include: 7. Patient #8 had a start of care date of 1/4/2022. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 10/14/2021. The document identified Medicare as the payer for Patient #8's services and identified Medicare would pay 100% for the patient's services. Documentation indicated the registered nurse (RN) reviewed the information verbally with the patient. The clinical record lacked documentation the patient was given a copy of the document or any other written information related to the patient's financial obligations for agency services. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 4. Patient #1 had a start of care date of 3/6/2021 and was discharged from agency on 9/1/2021. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 3/6/21. The document identified Medicaid would be billed for home health services, however, failed to identify the percentage of coverage and how much the patient could expect to pay out of pocket for his/her part of the payment for services. The document was signed by the RN and the patient's Power of Attorney. Documentation indicated the RN reviewed the information verbally with the patient's representative. The clinical record lacked documentation the patient's representative was given a copy of the document or any other written information related to the patient's financial obligations for agency services. 5. Patient #2 had a start of care date of 7/2/2021 and was discharged from the agency on 8/27/2021. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 7/9/21. The document identified Medicaid as the payer for Patient #2's services and identified Medicaid would pay 100% for the patient's services. Documentation indicated the registered nurse (RN) reviewed the information verbally with the patient. The clinical record lacked documentation the patient was given a copy of the document or any other written information related to the patient's financial obligations for agency services. 6. Patient #10 had a start of care date of 9/7/2021 and was discharged from the agency on 1/4/2022. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 9/7/21. The document identified Medicaid as the payer for Patient #10's services and identified Medicaid would pay 100% for the patient's services. Documentation indicated the RN reviewed the information verbally with the patient. The clinical record lacked documentation the patient was given a copy of the document or any other written information related to the financial obligations for agency services. 1. Patient #3 had a start of care date of 10/14/2021. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 10/14/2021. The document identified Medicare as the payer for Patient #3's services and identified Medicare would pay 100% for the patient's services. Documentation indicated the registered nurse (RN) reviewed the information verbally with the patient. The clinical record lacked documentation the patient was given a copy of the document or any other written information related to the patient's financial obligations for agency services. 2. Patient #4 had a start of care date of 3/11/2021. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 3/11/2021. The document failed to identify the payer who would be billed for the patient's home health services and failed to identify how much the patient could expect to pay out of pocket for his/her part of the payment for services. The document was signed by the RN and indicated the patient's representative would be signing the document due to Patient #4's intellectual disabilities; however, the form was not signed by the patient's representative. Documentation indicated the RN reviewed the information verbally with the patient's representative. The clinical record lacked documentation the patient's representative was given a copy of the document or any other written information related to the patient's financial obligations for agency services. 3. Patient #9 had a start of care date of 12/17/2021. Clinical record review revealed the following: The patient's clinical record included an electronic consent form, dated 12/17/2021. The document identified Medicare as the payer for Patient #9's services and identified Medicare would pay 100% for the patient's services. Documentation indicated the RN reviewed the information verbally with the patient. The clinical record lacked documentation the patient was given a copy of the document or any other written information related to the financial obligations for agency services.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to document the patient's behaviors and circumstances that warranted patient's discharge for cause and the agency's efforts to resolve the problems prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #2 and #10).Failure to document the patient's behaviors and circumstances that warranted patient's discharge prevented the patient of the ability to attempt to correct the issue prior to the involuntary discharge. 2. Patient #10 had a start of care date of 9/7/2021 and was discharged by the agency on 1/4/2022.Clinical record review revealed the following:a. The Plans of Care (POC), dated 9/7/21 to 11/5/21 and 11/6/21 to 1/4/22, included physician orders for skilled nurse visits to assess medications and report and monitor diabetic care and report low and high blood sugars. The POC also included physician orders for home health aide visits to assist with personal cares and activities of daily living secondary to functional limitations, which prevent self-care stating there is no willing or able caregiver to provide for hygiene needs. b. Skilled nurse visit notes, dated 11/15/22, 11/29/22, and 12/13/22, documented skilled nursing visits occurred as scheduled and documented the patient's noncompliance and poor living conditions. Physician notification occurred regarding the concerns of the patient's living environment. c. Client coordination notes, dated 12/16/21, 12/23/21, and 12/27/21, documented missed home health aide visits due to patient refusal as no answer at door or phone and the doctor was notified of the missed visits. d. Skilled nurse visit note, dated 12/30/22, documented the nurse went to the patient's house and had been trying to reach the patient by phone for several days. The patient would not answer the phone or return phone calls. The patient's door was unlocked and the nurse found the patient laying on couch in the living room. The patient was upset the nurse was in the home. The nurse informed the patient had been trying to reach the patient for a visit. The patient reported had no been feeling well and had been very fatigued and that is why not answering phone calls, knocks at door, or returning phone calls. The nurse reported patient was pale and helped the patient sit up to obtain vital signs. Heart rate was elevated at 120 beats per minute and blood pressure was elevated at 178/108. The patient reported had not checked blood sugar readings in 3 plus days. The patient was confused and did not know what day it was or time of day. The patient had swelling of bilateral lower extremities of 2 plus pitting edema below the knees. Bilateral lower extremities were were red and warm to touch with multiple large scabs noted. Upon exam of feet, the feet were red and warm and the patient had an old continuous glucose monitor sensor needle stuck in the ball of the foot. The patient was unaware it was there and stated the patient was unable to feel feet very well. The patient was experiencing pain all over. The nurse discussed with the patient and advised transport to the emergency room. The patient was initially resistant, but eventually agreed to allow the nurse to call the ambulance for transport. When the paramedics arrived, the nurse informed them of the patient's background and medical history and the patient was transported to the hospital. The nurse did contact the patient's primary care provider's office and spoke with a nurse regarding the patient's medical condition and notified the patient was transported to the emergency room. e. The update to the comprehensive assessment at the time of discharge, completed by a nurse and dated 1/4/22 documented data collection only and no in person visit was made for the discharge assessment. The patient's discharge disposition was the patient remained in the community without formal assistive services and the narrative note stated the patient was discharged from services as the patient continued to refuse visits, staff was unable to contact the patient, and the patient was noncompliant with care. The electronic signature of the visit was 1/16/22. The clinical record lacked any documentation of the agency communication attempts with the facility, patient, or provider to locate the patient and inform the patient of plans to discharge. f. The physician's order, dated 1/4/22, identified the patient discharged from services with the agency due to the patient not wanting services. g. The client coordination note completed by the nurse and sent to the physician, dated 1/16/22, included documentation the patient discharged from services due to continued refusals of visits and documented staff were unable to contact the patient, and the patient was noncompliant with care. The clinical record lacked documentation of efforts to resolve the behaviors of noncompliance. The surveyor attempted to contact the physician's office and Staff B, RN who performed the discharge assessment and did not receive any return phone calls. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled Patient Bill Of Rights, last revised April 2018, the patient has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so. The patient has the right to be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service. According to the agency policy titled Discharge Criteria and Process, last revised April 2018, services will be terminated when the patient meets 1 or more of the discharge criteria: conditions in the home are no longer safe for the patient or organization personnel, the patient and/or family display disruptive, abusive and uncooperative behavior. Discharge for cause: if the patient is being discharged for cause, the physician(s) issuing orders for the plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge will be notified. 1. Patient #2 had a start of care date of 7/9/21 and was discharged by the agency on 8/27/21.Clinical record review and associated patient and staff interviews included the following:a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for skilled nurse visits every week to set up medications, assess vital signs and physical assessment. The POC also included physician orders for home health aide 2 times a week to assist with personal cares, bathing and fall precautions.b. The physician's order, dated 8/27/2021, identified the patient discharged from services with the agency to promote staff safety. c. The nurse visit note, dated 8/27/21, included documentation when staff entered the patient's apartment, the patients spouse sat on the couch and appeared aggravated. The spouse stared at staff and tapped his/her foot and his/her face flushed. Staff took the patient's vital signs and asked about pain and began the assessment. Staff discussed the patient's schedule and recertification due next week to continue orders. The spouse stated staff will have to help the patient shower for the rest of his/her life. The nurse stated staff were there to educate and encourage independence and teach the spouse how to help the patient to shower. The spouse began to yell profanity at the nurse and stated she tells everyone how terrible the staff are and pointed his/her finger at the nurse. Two dogs in the patient's home presented increased danger. The patient's spouse walked toward the nurse while screaming obscenities. The nurse walked to the door to prevent physical aggression and protect herself. The spouse continued to scream and told the nurse to get out. Staff immediately telephoned her supervisor and told to leave the building for safety. The note included documentation of patient background: the patient had Post Traumatic Stress Disorder. Several voicemails from the patient and spouse using profanity and yelling which began the week of admission. d. During an interview on 4/13/21 at 3:30 PM, Staff B, RN (registered nurse) stated the patient admitted for home health services after the spouse had surgery. The spouse had been the caregiver for the patient. The patient exhibited verbal sapping at staff during services. The patient's nurse called her and reported concerns in the home due to screaming and yelling profanities to her. Staff B stated she called to discuss the behavior with the patient. The patient became irate. She explained they would need to discharge him/her from services and the patient stated "OK" and hung up the phone. e. During patient interview on 4/12/22 at 12:45 PM, he/she stated the agency called and told him/her that services would not be provided anymore. The clinical record lacked documentation of efforts to resolve the behaviors.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to notify the patient or the physician prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #2 and #10) Failure to provide patient's or their physician with notification that discharge for cause is being considered denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. 2. Patient #10 had a start of care date of 9/7/2021 and was discharged by the agency on 1/4/2022.Clinical record review revealed the following:a. The Plans of Care (POC), dated 9/7/21 to 11/5/21 and 11/6/21 to 1/4/22, included physician orders for skilled nurse visits to assess medications and report and monitor diabetic care and report low and high blood sugars. The POC also included physician orders for home health aide visits to assist with personal cares and activities of daily living secondary to functional limitations, which prevent self-care stating there is no willing or able caregiver to provide for hygiene needs. b. Skilled nurse visit notes, dated 11/15/22, 11/29/22, and 12/13/22, documented skilled nursing visits occurred as scheduled and documented the patient's noncompliance and poor living conditions. Physician notification occurred regarding the concerns of the patient's living environment. c. Client coordination notes, dated 12/16/21, 12/23/21, and 12/27/21, documented missed home health aide visits due to patient refusal as no answer at door or phone and the doctor was notified of the missed visits. d. Skilled nurse visit note, dated 12/30/22, documented the nurse went to the patient's house and had been trying to reach the patient by phone for several days. The patient would not answer the phone or return phone calls. The patient's door was unlocked and the nurse found the patient laying on couch in the living room. The patient was upset the nurse was in the home. The nurse informed the patient had been trying to reach the patient for a visit. The patient reported had no been feeling well and had been very fatigued and that is why not answering phone calls, knocks at door, or returning phone calls. The nurse reported patient was pale and helped the patient sit up to obtain vital signs. Heart rate was elevated at 120 beats per minute and blood pressure was elevated at 178/108. The patient reported had not checked blood sugar readings in 3 plus days. The patient was confused and did not know what day it was or time of day. The patient had swelling of bilateral lower extremities of 2 plus pitting edema below the knees. Bilateral lower extremities were were red and warm to touch with multiple large scabs noted. Upon exam of feet, the feet were red and warm and the patient had an old continuous glucose monitor sensor needle stuck in the ball of the foot. The patient was unaware it was there and stated the patient was unable to feel feet very well. The patient was experiencing pain all over. The nurse discussed with the patient and advised transport to the emergency room. The patient was initially resistant, but eventually agreed to allow the nurse to call the ambulance for transport. When the paramedics arrived, the nurse informed them of the patient's background and medical history and the patient was transported to the hospital. The nurse did contact the patient's primary care provider's office and spoke with a nurse regarding the patient's medical condition and notified the patient was transported to the emergency room. e. The update to the comprehensive assessment at the time of discharge, completed by a nurse and dated 1/4/22 documented data collection only and no in person visit was made for the discharge assessment. The patient's discharge disposition was the patient remained in the community without formal assistive services and the narrative note stated the patient was discharged from services as the patient continued to refuse visits, staff was unable to contact the patient, and the patient was noncompliant with care. The electronic signature of the visit was 1/16/22. The clinical record lacked any documentation of the agency communication attempts with the facility, patient, or provider to locate the patient and inform the patient of plans to discharge. f. The physician's order, dated 1/4/22, identified the patient discharged from services with the agency due to the patient not wanting services. g. The client coordination note completed by the nurse and sent to the physician, dated 1/16/22, included documentation the patient discharged from services due to continued refusals of visits and documented staff were unable to contact the patient, and the patient was noncompliant with care. The surveyor attempted to contact the physician's office and Staff B, RN who performed the discharge assessment and did not receive any return phone calls. The patient's clinical record lacked written documentation of notification of the patient or his/her physician that discharge for cause being considered. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled Patient Bill Of Rights, last revised April 2018, the patient has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so. The patient has the right to be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service. According to the agency policy titled Discharge Criteria and Process, last revised April 2018, services will be terminated when the patient meets 1 or more of the discharge criteria: conditions in the home are no longer safe for the patient or organization personnel, the patient and/or family display disruptive, abusive and uncooperative behavior. Discharge for cause: if the patient is being discharged for cause, the physician(s) issuing orders for the plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge will be notified. 1. Patient #2 had a start of care date of 7/9/21 and was discharged by the agency for cause on 8/27/21. Clinical record review and associated patient and staff interviews included the following: a. The Plans of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for skilled nurse visits every week to set up medications, assess vital signs and physical assessment. The POC also included physician orders for home health aide 2 times a week to assist with personal cares, bathing and fall precautions.b. The physician's order, dated 8/27/2021, identified the patient discharged from services with the agency to promote staff safety. c. The nurse visit note, dated 8/27/21, included documentation when staff entered the patient's apartment, the patients spouse sat on the couch and appeared aggravated. The spouse stared at staff and tapped his/her foot and his/her face flushed. Staff took the patient's vital signs and asked about pain and began the assessment. Staff discussed the patient's schedule and recertification due next week to continue orders. The spouse stated staff will have to help the patient shower for the rest of his/her life. The nurse stated staff were there to educate and encourage independence and teach the spouse how to help the patient to shower. The spouse began to yell profanity at the nurse and stated she tells everyone how terrible the staff are and pointed his/her finger at the nurse. Two dogs in the patient's home presented increased danger. The patient's spouse walked toward the nurse while screaming obscenities. The nurse walked to the door to prevent physical aggression and protect herself. The spouse continued to scream and told the nurse to get out. Staff immediately telephoned her supervisor and told to leave the building for safety. The note included documentation of patient background: the patient had Post Traumatic Stress Disorder. Several voicemails from the patient and spouse using profanity and yelling which began the week of admission. d. During an interview on 4/13/21 at 3:30 PM, Staff B, RN (registered nurse) stated the patient admitted for home health services after the spouse had surgery. The spouse had been the caregiver for the patient. The patient exhibited verbal sapping at staff during services. The patient's nurse called her and reported concerns in the home due to screaming and yelling profanities to her. Staff B stated she called to discuss the behavior with the patient. The patient became irate. She explained they would need to discharge him/her from services and the patient stated "OK" and hung up the phone. e. During patient interview on 4/12/22 at 12:45 PM, he/she stated the agency called and told him/her that services would not be provided anymore. The patient's clinical record lacked written documentation of notification of the patient or his/her physician that discharge for cause being considered. Collapse

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #2 and #10) .Failure to attempt to initiate any efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. 2. Patient #10 had a start of care date of 9/7/2021 and was discharged by the agency on 1/4/2022.Clinical record review revealed the following:a. The Plans of Care (POC), dated 9/7/21 to 11/5/21 and 11/6/21 to 1/4/22, included physician orders for skilled nurse visits to assess medications and report and monitor diabetic care and report low and high blood sugars. The POC also included physician orders for home health aide visits to assist with personal cares and activities of daily living secondary to functional limitations, which prevent self-care stating there is no willing or able caregiver to provide for hygiene needs. b. Skilled nurse visit notes, dated 11/15/22, 11/29/22, and 12/13/22, documented skilled nursing visits occurred as scheduled and documented the patient's noncompliance and poor living conditions. Physician notification occurred regarding the concerns of the patient's living environment. c. Client coordination notes, dated 12/16/21, 12/23/21, and 12/27/21, documented missed home health aide visits due to patient refusal as no answer at door or phone and the doctor was notified of the missed visits. d. Skilled nurse visit note, dated 12/30/22, documented the nurse went to the patient's house and had been trying to reach the patient by phone for several days. The patient would not answer the phone or return phone calls. The patient's door was unlocked and the nurse found the patient laying on couch in the living room. The patient was upset the nurse was in the home. The nurse informed the patient had been trying to reach the patient for a visit. The patient reported had no been feeling well and had been very fatigued and that is why not answering phone calls, knocks at door, or returning phone calls. The nurse reported patient was pale and helped the patient sit up to obtain vital signs. Heart rate was elevated at 120 beats per minute and blood pressure was elevated at 178/108. The patient reported had not checked blood sugar readings in 3 plus days. The patient was confused and did not know what day it was or time of day. The patient had swelling of bilateral lower extremities of 2 plus pitting edema below the knees. Bilateral lower extremities were were red and warm to touch with multiple large scabs noted. Upon exam of feet, the feet were red and warm and the patient had an old continuous glucose monitor sensor needle stuck in the ball of the foot. The patient was unaware it was there and stated the patient was unable to feel feet very well. The patient was experiencing pain all over. The nurse discussed with the patient and advised transport to the emergency room. The patient was initially resistant, but eventually agreed to allow the nurse to call the ambulance for transport. When the paramedics arrived, the nurse informed them of the patient's background and medical history and the patient was transported to the hospital. The nurse did contact the patient's primary care provider's office and spoke with a nurse regarding the patient's medical condition and notified the patient was transported to the emergency room. e. The update to the comprehensive assessment at the time of discharge, completed by a nurse and dated 1/4/22 documented data collection only and no in person visit was made for the discharge assessment. The patient's discharge disposition was the patient remained in the community without formal assistive services and the narrative note stated the patient was discharged from services as the patient continued to refuse visits, staff was unable to contact the patient, and the patient was noncompliant with care. The electronic signature of the visit was 1/16/22. The clinical record lacked any documentation of the agency communication attempts with the facility, patient, or provider to locate the patient and inform the patient of plans to discharge. f. The physician's order, dated 1/4/22, identified the patient discharged from services with the agency due to the patient not wanting services. g. The client coordination note completed by the nurse and sent to the physician, dated 1/16/22, included documentation the patient discharged from services due to continued refusals of visits and documented staff were unable to contact the patient, and the patient was noncompliant with care. The surveyor attempted to contact the physician's office and Staff B, RN who performed the discharge assessment and did not receive any return phone calls. The patient's clinical record lacked documentation of any efforts made to resolve the problem prior to discharge. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled Patient Bill Of Rights, last revised April 2018, the patient has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so. The patient has the right to be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service. According to the agency policy titled Discharge Criteria and Process, last revised April 2018, services will be terminated when the patient meets 1 or more of the discharge criteria: conditions in the home are no longer safe for the patient or organization personnel, the patient and/or family display disruptive, abusive and uncooperative behavior. Discharge for cause: if the patient is being discharged for cause, the physician(s) issuing orders for the plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge will be notified. 1. Patient #2 had a start of care date of 7/9/21 and was discharged by the agency for cause on 8/27/21. Clinical record review and associated patient and staff interviews included the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for skilled nurse visits every week to set up medications, assess vital signs and physical assessment. The POC also included physician orders for home health aide 2 times a week to assist with personal cares, bathing and fall precautions.b. The physician's order, dated 8/27/2021, identified the patient discharged from services with the agency to promote staff safety. c. The nurse visit note, dated 8/27/21, included documentation when staff entered the patient's apartment, the patients spouse sat on the couch and appeared aggravated. The spouse stared at staff and tapped his/her foot and his/her face flushed. Staff took the patient's vital signs and asked about pain and began the assessment. Staff discussed the patient's schedule and recertification due next week to continue orders. The spouse stated staff will have to help the patient shower for the rest of his/her life. The nurse stated staff were there to educate and encourage independence and teach the spouse how to help the patient to shower. The spouse began to yell profanity at the nurse and stated she tells everyone how terrible the staff are and pointed his/her finger at the nurse. Two dogs in the patient's home presented increased danger. The patient's spouse walked toward the nurse while screaming obscenities. The nurse walked to the door to prevent physical aggression and protect herself. The spouse continued to scream and told the nurse to get out. Staff immediately telephoned her supervisor and told to leave the building for safety. The note included documentation of patient background: the patient had Post Traumatic Stress Disorder. Several voicemails from the patient and spouse using profanity and yelling which began the week of admission. d. During an interview on 4/13/21 at 3:30 PM, Staff B, RN (registered nurse) stated the patient admitted for home health services after the spouse had surgery. The spouse had been the caregiver for the patient. The patient exhibited verbal sapping at staff during services. The patient's nurse called her and reported concerns in the home due to screaming and yelling profanities to her. Staff B stated she called to discuss the behavior with the patient. The patient became irate. She explained they would need to discharge him/her from services and the patient stated "OK" and hung up the phone. e. During patient interview on 4/12/22 at 12:45 PM, he/she stated the agency called and told him/her that services would not be provided anymore. The patient's clinical record lacked documentation of any efforts made to resolve the problem prior to discharge. The above findings for Patient #2 were reviewed with the agency Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to provide the patient with contact information for other agencies or providers who may be able to provide care prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #2 and #10) The agency reported discharging 110 patients between 3/11/21 and 3/11/22. Failure to provide the patient with contact information of other agencies or providers who may be able to provide care after an involuntary discharge placed the patient at risk for inadequate care in the home setting to meet the needs of the patient, increasing the risk of illness or injury due lack of oversight. Findings include: According to agency policy, titled Discharge Criteria and process, dated 4/2018, services will be terminated when the patient meets one or more of the discharge criteria, including the patient or family/caregiver refuses to cooperate in attaining the objectives of home care and /or the patient and/or family display disruptive, abusive, and uncooperative behavior. The organization will verbally notify the patient the decision to terminate or reduce services within one visit prior to the time the change in service is to occur (i.e., prior to the last scheduled visit. Prior notice will not be necessary when services are discontinued by the patient or physician, however, action taken must be documented in the clinical record and a discharge summary completed. A copy of the discharge instructions will be mailed to the patient. An update to the comprehensive assessment will be completed. For a patient requiring continuing care, assistance will be given to the patient and family/caregiver in order to manage continuing care needs after the agency services are discontinued. Discharge instructions will be provided. Discharge planning will identify needs the patient may have and arrangements for such services will be coordination the the organization when applicable. 1. Patient #2 had a start of care date of 7/9/21 and was discharged by the agency for cause on 8/27/21. (See G462) The patient's clinical record lacked documentation of providing the patient or patient representative with contact information for other agencies or providers who may be able to provide care. 2. Patient #10 had a start of care date of 9/7/2021 and was discharged by the agency on 1/4/2022. (See G462) The patient's clinical record lacked documentation of providing the patient or patient representative with contact information for other agencies or providers who may be able to provide care. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 2 of 2 sampled patients discharged for behaviors or non-compliance (Patients #2 and #10). Failure to document the problems and efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. 2. Patient #10 had a start of care date of 9/7/2021 and was discharged by the agency on 1/4/2022.Clinical record review revealed the following:a. The Plans of Care (POC), dated 9/7/21 to 11/5/21 and 11/6/21 to 1/4/22, included physician orders for skilled nurse visits to assess medications and report and monitor diabetic care and report low and high blood sugars. The POC also included physician orders for home health aide visits to assist with personal cares and activities of daily living secondary to functional limitations, which prevent self-care stating there is no willing or able caregiver to provide for hygiene needs. b. Skilled nurse visit notes, dated 11/15/22, 11/29/22, and 12/13/22, documented skilled nursing visits occurred as scheduled and documented the patient's noncompliance and poor living conditions. Physician notification occurred regarding the concerns of the patient's living environment. c. Client coordination notes, dated 12/16/21, 12/23/21, and 12/27/21, documented missed home health aide visits due to patient refusal as no answer at door or phone and the doctor was notified of the missed visits. d. Skilled nurse visit note, dated 12/30/22, documented the nurse went to the patient's house and had been trying to reach the patient by phone for several days. The patient would not answer the phone or return phone calls. The patient's door was unlocked and the nurse found the patient laying on couch in the living room. The patient was upset the nurse was in the home. The nurse informed the patient had been trying to reach the patient for a visit. The patient reported had no been feeling well and had been very fatigued and that is why not answering phone calls, knocks at door, or returning phone calls. The nurse reported patient was pale and helped the patient sit up to obtain vital signs. Heart rate was elevated at 120 beats per minute and blood pressure was elevated at 178/108. The patient reported had not checked blood sugar readings in 3 plus days. The patient was confused and did not know what day it was or time of day. The patient had swelling of bilateral lower extremities of 2 plus pitting edema below the knees. Bilateral lower extremities were were red and warm to touch with multiple large scabs noted. Upon exam of feet, the feet were red and warm and the patient had an old continuous glucose monitor sensor needle stuck in the ball of the foot. The patient was unaware it was there and stated the patient was unable to feel feet very well. The patient was experiencing pain all over. The nurse discussed with the patient and advised transport to the emergency room. The patient was initially resistant, but eventually agreed to allow the nurse to call the ambulance for transport. When the paramedics arrived, the nurse informed them of the patient's background and medical history and the patient was transported to the hospital. The nurse did contact the patient's primary care provider's office and spoke with a nurse regarding the patient's medical condition and notified the patient was transported to the emergency room. e. The update to the comprehensive assessment at the time of discharge, completed by a nurse and dated 1/4/22 documented data collection only and no in person visit was made for the discharge assessment. The patient's discharge disposition was the patient remained in the community without formal assistive services and the narrative note stated the patient was discharged from services as the patient continued to refuse visits, staff was unable to contact the patient, and the patient was noncompliant with care. The electronic signature of the visit was 1/16/22. The clinical record lacked any documentation of the agency communication attempts with the facility, patient, or provider to locate the patient and inform the patient of plans to discharge. f. The physician's order, dated 1/4/22, identified the patient discharged from services with the agency due to the patient not wanting services. g. The client coordination note completed by the nurse and sent to the physician, dated 1/16/22, included documentation the patient discharged from services due to continued refusals of visits and documented staff were unable to contact the patient, and the patient was noncompliant with care. The surveyor attempted to contact the physician's office and Staff B, RN who performed the discharge assessment and did not receive any return phone calls. The patient's clinical record lacked documentation of any problems and efforts made to resolve the problem prior to discharge. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled Patient Bill Of Rights, last revised April 2018, the patient has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so. The patient has the right to be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service. According to the agency policy titled Discharge Criteria and Process, last revised April 2018, services will be terminated when the patient meets 1 or more of the discharge criteria: conditions in the home are no longer safe for the patient or organization personnel, the patient and/or family display disruptive, abusive and uncooperative behavior. Discharge for cause: if the patient is being discharged for cause, the physician(s) issuing orders for the plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge will be notified. 1. Patient #2 had a start of care date of 7/9/21 and was discharged by the agency for cause on 8/27/21. Clinical record review and associated patient and staff interviews included the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for skilled nurse visits every week to set up medications, assess vital signs and physical assessment. The POC also included physician orders for home health aide 2 times a week to assist with personal cares, bathing and fall precautions.b. The physician's order, dated 8/27/2021, identified the patient discharged from services with the agency to promote staff safety. c. The nurse visit note, dated 8/27/21, included documentation when staff entered the patient's apartment, the patients spouse sat on the couch and appeared aggravated. The spouse stared at staff and tapped his/her foot and his/her face flushed. Staff took the patient's vital signs and asked about pain and began the assessment. Staff discussed the patient's schedule and recertification due next week to continue orders. The spouse stated staff will have to help the patient shower for the rest of his/her life. The nurse stated staff were there to educate and encourage independence and teach the spouse how to help the patient to shower. The spouse began to yell profanity at the nurse and stated she tells everyone how terrible the staff are and pointed his/her finger at the nurse. Two dogs in the patient's home presented increased danger. The patient's spouse walked toward the nurse while screaming obscenities. The nurse walked to the door to prevent physical aggression and protect herself. The spouse continued to scream and told the nurse to get out. Staff immediately telephoned her supervisor and told to leave the building for safety. The note included documentation of patient background: the patient had Post Traumatic Stress Disorder. Several voicemails from the patient and spouse using profanity and yelling which began the week of admission. d. During an interview on 4/13/21 at 3:30 PM, Staff B, RN (registered nurse) stated the patient admitted for home health services after the spouse had surgery. The spouse had been the caregiver for the patient. The patient exhibited verbal sapping at staff during services. The patient's nurse called her and reported concerns in the home due to screaming and yelling profanities to her. Staff B stated she called to discuss the behavior with the patient. The patient became irate. She explained they would need to discharge him/her from services and the patient stated "OK" and hung up the phone. e. During patient interview on 4/12/22 at 12:45 PM, he/she stated the agency called and told him/her that services would not be provided anymore. The patient's clinical record lacked documentation of any problems and efforts made to resolve the problem prior to discharge.

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 agency policy review, clinical record review, patient/caregiver interview and agency staff interview, the agency failed to do the following: 1) ensure completion of all components of the drug regimen review with recertification, resumption of care and discharge comprehensive assessments (G536); 2) ensure comprehensive assessments were updated and revised the last five days of every 60 day period beginning with start of care (G546); 3) ensure comprehensive assessments were updated and revised 2 days after receiving knowledge of the patient's return home from an inpatient stay (G548); and 4) ensure comprehensive assessments were updated at discharge by assessing the patient directly in the patient's home or by the last qualified clinician who assessed the patient directly in the case of an unexpected discharge where the nurse cannot visit the patient (G550); The systemic practice resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of agency patients.

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 update to the comprehensive assessment at the time of resumption of care, recertification and discharge for 14 of 15 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14 and #15). 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: 14. Patient #5 had a start of care date of 3/17/12, transfer date of 1/24/22 and discharge date of 2/24/22. a. The POC, dated 1/14/22 to 3/14/22, identified the patient had orders for medications and skilled nursing and home health services. b. The transfer order, dated 1/25/21, identified the patient transferred to the hospital from the agency. c. The skilled nurse visit note dated 2/1/22 identified the ROC, resumption of care d. The discharge transfer summary report, dated 2/24/22, identified the patient discharged from the agency. e. The DRR, (drug regimen review), dated 1/10/22, 1/20/22 and 2/17/22, revealed the DRR not completed on patient ROC, (resumption of care), 2/1/22 and discharge on 2/24/22. The agency failed to complete the drug regimen review after the patient returned home from a hospital admission and upon discharge from the agency. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 10. Patient #1 had a start of care date of 3/6/2021 and was transferred to inpatient facility on 8/10/2021 Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of recertification, dated as started on 7/2/22, was not completed until 7/8/22. The Medication Report located in the patient's electronic clinical record included documentation of a drug regimen review, dated 7/8/22. The recertification comprehensive assessment with accompanying drug regimen review needed to be completed within the last 5 days of the Plan of Care certification period of 5/5/21 to 7/3/21. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of the 7/2/22 recertification. b. The update to the comprehensive assessment at the time of resumption of care, dated 7/9/21, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after the 7/8/21. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of resumption of care. 11. Patient #6 had a start of care date of 8/28/2015 and was discharged from agency services on 3/42022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 3/4/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after recertification on 1/21/2022. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 12. Patient #10 had a start of care date of 9/7/2021 and was discharged from agency services on 1/4/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated as started on 1/4/22, but not electronically signed as completed until 1/16/22, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after recertification on 11/1/21. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 13. Patient #15 had a start of care date of 6/23/2021 and was discharged from agency services on 3/8/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 3/8/22, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after recertification on 2/15/22. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 8. Patient #2 had a start of care date of 7/9/21 and discharge date of 8/27/21. a. The POC, dated 7/9/21 to 9/6/21, identified the patient had orders for medications and skilled nursing and home health services. b. The discharge order, dated 8/27/21, identified the patient discharged from the agency. c. The drug regimen review, dated 7/9/21 and 8/13/21, revealed the drug regimen not completed on patient discharge on 8/27/21. 9. Patient #3 had a start of care date of 10/14/21 and discharge date of 2/21/22. a. The Plans of Care (POC), dated 10/14/21 to 12/10/21, 12/11/21 to 2/8/22 and 2/9/22 to 4/11/22, identified the patient had orders for medications and skilled nursing services. b. The client episode coordination note report, dated 11/3/21, documented the patient admitted to the hospital. c. The comprehensive assessment at the resumption of care, dated 11/8/21, documented the patient discharged form the hospital on 11/5/21. d. The drug regimen review, dated 11/9/21, completed 4 days after discharge from the hospital (2 days late). The agency failed to complete the drug regimen review within 48 hours after the patient returned home from a hospital admission. According to the agency policy, titled Medication Profile and dated 4/2018, the drug regimen review as part of the comprehensive assessment will be completed at admission, with updates to the comprehensive assessment and when care is resumed after services placed on hold. The review will include identification of duplication of medications, ineffective medications, side effects, non-compliance and medication interactions. During agency staff interview on 4/11/2022 at 10:57 AM, the Clinical Manager reported the clinicians assess all medications with each visit and document the assessment within the visit note. 1. Patient #4 had a start of care date of 3/11/2021 and was discharged from agency services on 3/11/2022. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of recertification, dated 9/3/2021, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record included documentation of a drug regimen review, dated 9/13/2021. The recertification comprehensive assessment with accompanying drug regimen review needed to be completed within the last 5 days of the Plan of Care certification period of 7/9/2021 to 9/6/2021. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of the 9/3/2021 recertification. b. The update to the comprehensive assessment at the time of discharge, dated 3/4/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by a registered nurse (RN) after 1/3/2022. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 2. Patient #7 had a start of care date of 10/13/2016 and was discharged from agency services on 3/11/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 3/11/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after the 1/11/2022. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 3. Patient #9 had a start of care date of 12/17/2021 and was discharged from agency services on 2/4/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 2/4/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after admission on 12/17/2021. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 4. Patient #11 had a start of care date of 12/15/2012 and was discharged from agency services on 2/25/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 2/25/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after 12/23/2021. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 5. Patient #12 had a start of care date of 11/12/2021 and was discharged from agency services on 3/2/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 3/2/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after 1/18/2022. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 6. Patient #13 had a start of care date of 10/18/2021 and was discharged from agency services on 3/8/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 3/8/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after 2/11/2022. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge. 7. Patient #14 had a start of care date of 9/6/2012 and was discharged from agency services on 3/7/2022. Clinical record review revealed the following: The update to the comprehensive assessment at the time of discharge, dated 3/7/2022, lacked any documentation of a drug regimen review. The Medication Report located in the patient's electronic clinical record lacked documentation of any drug regimen reviews completed by an RN after 2/8/2022. The clinical record lacked documentation of any drug regimen review to accompany the update to the comprehensive assessment at the time of discharge.

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 2 of 7 sampled patients requiring a recertification assessment (Patients #1 and #4). 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: 2. Patient #1 had a start of care date of 3/6/2021 and was transferred to inpatient facility on 8/10/2021. Clinical record revealed: a. The Plans of Care, dated 3/6/21 to 5/4/21, 5/5/21 to 7/3/21, and 7/4/21 to 9/1/21, included physician orders for skilled nursing and home health aide services. An update to the comprehensive assessment for recertification, dated as initiated on 7/2/21 but was not electronically signed as completed until 7/8/21, day 5 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, making the assessment 5 days late. agency failed to update the comprehensive assessments in the last 5 days of each 60 day episode. The surveyors reviewed the above findings with agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey. According to the agency policy, titled Initial and Comprehensive Assessment Policy and dated 4/2018, a comprehensive assessment for recertification will be completed "within the last five days of every 60 day episode, beginning with the start of care, (recertification)". 1. Patient #4 had a start of care date of 3/11/2021 and was discharged from agency services on 3/4/2022. Clinical record revealed: a. The Plans of Care, dated 5/10/2021 to 7/8/2021 and 7/9/2021 to 9/6/2021, included physician orders for skilled nursing and home health aide services. An update to the comprehensive assessment for recertification, dated as initiated on 7/7/2021 but was not electronically signed as completed until 7/12/2021, day 4 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, making the assessment 4 days late. b. The Plans of Care, dated 7/9/2021 to 9/6/2021 and 9/7/2021 to 11/5/2021, included physician orders for skilled nursing and home health aide services. An update to the comprehensive assessment for recertification, dated as initiated on 9/3/2021 but was not electronically signed as completed until 9/12/2021, day 7 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, making the assessment 7 days late. c. The Plans of Care, dated 11/6/2021 to 1/4/2022 and 1/5/2022 to 3/5/2022, included physician orders for skilled nursing and home health aide services. An update to the comprehensive assessment for recertification, dated as initiated on 1/3/2022 but was not electronically signed as completed until 1/7/2022, day 3 into the new certification period. The assessment was not completed by day 60 as required by regulation and agency policy, making the assessment 3 days late. The agency failed to update the comprehensive assessments in the last 5 days of each 60 day episode.

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 2 of 4 sampled patients requiring a resumption of care assessment (Patient #1 and #3). The agency performed 5 resumption of care assessments in the past 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: 2. Patient #3 had a start of care date of 10/14/21 and discharge date of 2/21/22. a. The Plans of Care (POC), dated 10/14/21 to 12/10/21, 12/11/21 to 2/8/22 and 2/9/22 to 4/11/22, included orders for skilled nursing services. b. The client episode coordination note report, dated 11/3/21, documented the patient admitted to the hospital. c. The skilled nurse visit note at resumption of care, dated 11/8/21, documented the patient discharged form the hospital on 11/5/21 (1 day late). The agency failed to complete the comprehensive assessment within 48 hours after the patient returned home from a hospital admission. The above findings were reviewed with agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey. According to the agency's policy, titled Initial and Comprehensive Assessment and dated April 2018, the patient specific comprehensive assessment must be performed within 48 hours of the patient's return home from a 24 hour hospital admission for admission other than diagnostic testing or on the physician ordered resumption of care date. 1. Patient #1 had a start of care date of 3/6/2021 and was transferred to inpatient facility on 8/10/21. Clinical record review revealed the following: a. The update to the comprehensive assessment for transfer to inpatient facility, dated 7/9/21, documented the patient went to the emergency room on 7/4/21 and was admitted as an inpatient on 7/6/21. b. The update to the comprehensive assessment for resumption of care, dated 7/9/21, included an electronic signature of completion of 7/15/21 (4 days late). The agency failed to complete the comprehensive assessment within 48 hours after the patient returned home from a hospital admission.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review, the agency failed to ensure completion of discharge comprehensive assessments were completed within 2 calendar days of identification of the need to discharge a patient by a clinician who had provided care to the patient directly for 3 of 15 sampled patients requiring a discharge comprehensive assessment (Patients #7, #10 and #11). Failure to accurately and thoroughly complete timely discharge comprehensive assessments by a clinician familiar with the patient increased the potential the patient may not receive referrals or continued care following discharge in a manner adequate to meet individualized needs of the patient. Findings include: 3. Patient #10 had a start of care date of 9/7/2021 and was discharged from agency services on 1/4/2022. Clinical record review revealed the following: a. The Plans of Care, dated 9/7/21 to 11/5/2021 and 1/6/21 to 1/4/22, included physician orders for skilled nursing and home health aide services. b. The skilled nurse visit notes, dated 11/15/21 and 11/29/21, were all completed by Staff E, Registered Nurse (RN). c. The skilled nurse visit notes, dated 12/13/21 and 12/30/21, were all completed by Staff D, Registered Nurse (RN). d. The updates to the comprehensive assessment at the time of recertification, dated 9/7/2021 and 11/1/21, were both completed by Staff E, RN. e. The update to the comprehensive assessment at the time of discharge, dated as initiated on 1/4/2022, was completed by Staff B, RN. No home visit was made to collect the assessment findings. The document indicated the assessment was completed by completing OASIS (Outcome and Assessment Information Set) data collection only, coded by Staff B, RN. The assessment documented an electronic signature of date of completion of 1/16/22. There was no evidence within the patient's electronic clinical record between 9/7/2021 and 1/4/22 indicating Staff B, RN, had ever provided any direct patient contact with Patient #10 and the discharge assessment was not completed within two business days of the date of discharge. The surveyors reviewed the above findings with the agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey. 1. Patient #7 had a start of care date of 10/13/2016 and was discharged from agency services on 3/11/2021. Clinical record review revealed the following: The Plans of Care, dated 7/20/2021 to 9/16/2021, 9/17/2021 to 11/15/2021, 11/16/2021 to 1/14/2022 and 1/15/2022 to 3/15/2022, included physician orders for skilled nursing and home health aide services. The skilled nurse visit notes, dated 1/13,20,27/2022; 2/3,10,17,24/2022 and 3/3/2022, were all completed by Staff D, Registered Nurse (RN). The updates to the comprehensive assessment at the time of recertification, dated 11/11/2021 and 1/11/2022, were both completed by Staff D, RN. The update to the comprehensive assessment at the time of discharge, dated 3/11/2022, was completed by Staff B, RN. No home visit was made to collect the assessment findings. The document indicated the assessment was completed by completing OASIS (Outcome and Assessment Information Set) data collection only, coded by Staff B, RN. There was no evidence within the patient's electronic clinical record between 7/20/2021 and 3/11/2022 indicating Staff B, RN, had ever provided any direct patient contact with Patient #7. 2. Patient #11 had a start of care date of 12/153/2012 and was discharged from agency services on 2/25/2022. Clinical record review revealed the following: The Plans of Care, dated 10/29/2021 to 12/27/2021 and 12/28/2021 to 2/25/2022, included physician orders for skilled nursing and home health aide services. The skilled nurse visit notes, dated 11/3,16/2021; 12/1,15,29/2021; 1/12,26/2022; and 2/9/2022, were all completed by Staff D, RN. The updates to the comprehensive assessment at the time of recertification, dated 12/23/2021 and 2/23/2022, were both completed by Staff D, RN. The update to the comprehensive assessment at the time of discharge, dated 2/25/2022, was completed by Staff B, RN. No home visit was made to collect the assessment findings. The document indicated the assessment was completed by completing OASIS (Outcome and Assessment Information Set) data collection only, coded by Staff B, RN. Staff B, RN, did not create the document or electronically sign the document as complete until 3/9/2022, 12 days after the patient had already been discharged. There was no evidence within the patient's electronic clinical record between 11/3/2021 and 2/25/2022 indicating Staff B, RN, had ever provided any direct patient contact with Patient #11.

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 agency policy review and clinical record review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient or caregiver to meet the patient's needs for 3 of 10 sampled patients (Patients #4, #7 and #10). 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: 3. Patient #10 had a start of care date of 9/7/2021 and was discharged from the agency on 1/4/2022. Clinical record review revealed the following: a. The Plans of Care, dated 9/7/21 to 11/5/21 and 11/6/21 to 1/4/22, identified the following equipment as supplies as needed to meet the patient's needs: lancets, continuous glucose monitor, glucometer, wheelchair, and cane. b. The updates to the comprehensive assessment at the time of recertification, dated 9/7/21 and 11/1/21, documented the patient was incontinent of urine and bowel. The 11/1/21, also included narrative documentation the patient wore depends undergarments 24 hours per day and seldom disposes of the soiled in the trash and the home was cluttered with depends. c. The skilled nurse visit notes, dated 11/15/21 and 12/13/21, documented the patient's use of depends. The Plans of Care lacked identification of incontinence supplies as medical equipment/supplies used to meet the patient's needs. The surveyors reviewed the above stated findings with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. According to agency policy, titled Care Planning Process and dated 4/2018, the individualized Plan of Care must include..... "supplies and equipment required". 1. Patient #4 had a start of care date of 3/11/21 and was discharged from agency services on 3/11/2022. Clinical record review revealed the following: a. The update to the comprehensive assessment, dated 5/5/2021, documented Patient #4 began using a bedside commode. The Home Health Aide Care Plans, dated 5/10/2021, 7/9/2021, 9/7/2021, 11/6/2021, 1/5/2022 and 1/31/2022, documented the patient used a bedside commode for elimination. The Plans of Care, dated 9/7/2021 to 11/5/2021, 11/6/2021 to 1/4/2022 and 1/5/2022 to 3/5/2022, lacked inclusion of the bedside commode as used by Patient #4 for elimination needs. b. The updates to the comprehensive assessment, dated 7/7/2021, 9/3/2021, 11/2/2021 and 1/3/2022, documented Patient #4 experienced incontinence of urine. The Plans of Care, dated 9/7/2021 to 11/5/2021, 11/6/2021 to 1/4/2022 and 1/5/2022 to 3/5/2022, lacked inclusion of incontinence products as used by Patient #4 for urinary incontinence between toileting. c. The updates to the comprehensive assessment, dated 7/7/2021, 9/3/2021, 11/2/2021 and 1/3/2022, documented Patient #4 used a hand held shower head when showering. The Home Health Aide Care Plans, dated 5/10/2021, 7/9/2021, 9/7/2021, 11/6/2021, 1/5/2022 and 1/31/2022, directed the aide to assist the patient with showering using a hand held shower head. The Plans of Care, dated 9/7/2021 to 11/5/2021, 11/6/2021 to 1/4/2022 and 1/5/2022 to 3/5/2022, lacked inclusion of hand held shower head as equipment used by Patient #4 to shower. 2. Patient #7 had a start of care of 10/13/2016 and was discharged from agency services on 3/11/2022. Clinical record review revealed the following: The Home Health Aide Care Plans, dated 9/14/2021, 11/12/2021, 11/16/2021 and 1/15/2022, directed the aide to assist the patient with showering using a non-slip tub mat. The Plans of Care, dated 9/17/2021 to 11/15/2021, 11/16/2021 to 1/14/2022 and 1/15/2022 to 3/15/2022, lacked inclusion of the non-slip tub mat as used by the patient when showering.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 6 of 6 sampled patients with new verbal/interim orders. (Patients #1, #2, #3, #5, #6 and #8) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 5. Patient #5 had a start of care date of 3/7/12 and discharge date of 2/24/22. The Plans of Care, dated, 11/14/22 to 1/13/22 and 1/14/22 to 3/14/22 included the diagnosis of chronic obstructive pulmonary disease and orders for skilled nursing services. The patient's clinical record lacked documentation of any working Plan of Care (a document used to capture all changes in the 60 day certification period that will allow all clinicians to use one Plan to identify any changes, deletions or additions to the original Plan). The clinical record included the following physician orders: a. 1/6/22, increase Zoloft to 100 mg 1 tablet in AM, discontinue Zoloft 50 mg 1 tablet in AM. b. 1/20/22, increase Abilify to 15mg, 1 tablet every AM, discontinue Abilify 5mg, 2 tablets daily. c. 2/4/22, SN, skilled nurse visit 2/7/22 for medication set up. d. 2/17/22, Change dose time for venlafaxine and sertraline from morning to bedtime. The clinical record lacked documentation of a Plan of Care update for the certification periods, dated, 11/14/22 to 1/13/22 and 1/14/22 to 3/14/22 which included physician orders for changes for medications and frequencies for skilled nurse. 6. Patient #8 had a start of care date of 1/4/22 and discharge date of 3/3/22. The Plan of Care, dated, 1/4/22 to 3/4/22 included the diagnosis of sepsis and orders for skilled nursing services. The patient's clinical record lacked documentation of any working Plan of Care (a document used to capture all changes in the 60 day certification period that will allow all clinicians to use one Plan to identify any changes, deletions or additions to the original Plan.). The clinical record included the following physician orders: a. 1/8/22, change dressing every Monday Wednesday and Friday and PRN if loose of falls off. 1. Cleanse with VASHE. 2. Dry. 3. Cover with hydrocolloid dressing. Add catheter supplies, gloves and wound care supplies. b. 1/12/22, Left shin wound care: change dressing 2 to 3 times weekly. Cleanse area with VASHE, dry, apply xeroform dressing, cover with ABD, (abdominal dressing) and rolled gauze, apply tubigrip G over area. SN to perform 1 time weekly caregiver to perform 1-2 times weekly. c. 1/12/22, PT, (physical therapy), frequency order, effective 1/9/22, 2 times a week for 4 weeksd. 1/28/22, Cephalexin 250mg 4 times daily for 10 days, discontinue oxybutynin. e. 1/28/22, SN, (skilled nurse), visit 1/28/22 for assessment post catheter removal, SN effective 1/23/22, 2 times a week for 1 week then 1 time a week for 5 weeks. The clinical record lacked documentation of a Plan of Care update for the certification period, dated, 1/4/22 to 3/4/22 which included physician orders for changes for wound care, medications and frequencies for skilled nurse and physical therapy. The agency failed to document all verbal orders on a working care plan. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. 3. Patient #2 had a start of care date of 7/9/21 and discharge date of 8/27/21. The Plans of Care, dated 7/9/21 to 9/6/21, included the diagnosis of cerebral infarction and orders for skilled nursing and home health aide services. The patient's clinical record lacked documentation of any working Plan of Care (a document used to capture all changes in the 60 day certification period that will allow all clinicians to use one Plan to identify any changes, deletions or additions to the original Plan.) a. The physician order, dated 8/13/21, included the order for gabapentin 100 mg (milligram) 2 times a day and take atorvastatin at night. The clinical record lacked documentation of a Plan of Care update for the certification period, dated 7/20/18 to 9/17/18, which included the physician orders for gabapentin and atorvastatin. The agency failed to document all verbal orders on a working care plan. 4. Patient #3 had a start of care date of 10/14/21 and discharge date of 2/21/22. The Plans of Care, dated 10/14/21 to 12/12/21, 12/13/21 to 2/10/22 and 2/11/22 to 4/11/22, included the diagnosis of acute and chronic respiratory failure and orders for skilled nursing services. The patient's clinical record lacked documentation of any working Plan of Care (a document used to capture all changes in the 60 day certification period that will allow all clinicians to use one Plan to identify any changes, deletions or additions to the original Plan.) a. The clinical record included the following physician orders: 12/27/21, included the order for coumadin 3 mg daily. 1/12/22 hold coumadin today and start coumadin 2.5 mg daily on 1/13/22. 1/18/22 levaquin 500 mg for 10 days. 2/3/22 coumadin 3 mg daily and xanax 0.25 mg every hour of sleep as needed for anxiety. The clinical record lacked documentation of a Plan of Care update for the certification period, dated 12/13/21 to 2/10/22 and 2/11/22 to 4/11/22, which included the physician orders for changes for coumadin orders, levaquin and xanax. The agency failed to document all verbal orders on a working care plan. According to agency policy, titled Care Planning Process, dated 4/2018, the Plan of Care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessment of the patient. The patient/representative/caregiver will be involved in any change in care of services. Revision dates will be noted on the Plan of Care. On 4/11/22 at 10:57 AM, interview with the Clinical Manager revealed interim physician orders are incorporated into an updated Plan of Care, however the Clinical Manager was not sure where that was documented. 1. Patient #1 had a start of care date of 3/6/21 and transferred to inpatient facility on 8/10/21. Clinical record revealed the following: a. The Plan of Care, dated 7/4/21 to 9/1/21, included a visit frequency for skilled nurse visits weekly for one week and for home health aide weekly for one week. b. An interim physician's order, dated 7/9/21, ordered to resume home care services. c. An interim physician's order, dated 7/9/21, included changes in visit frequency effective 7/4/21 for skilled nursing weekly for one week, three times per week for seven weeks and twice per week for one week and effective 7/11/21 for home health aide visits three times per week for seven weeks and then twice per week for one week. The clinical record lacked documentation of a Plan of Care update including all patient care orders. 2. Patient #6 had a start of care date of 8/28/2015 and was discharged from the agency on 3/4/2022. Clinical record revealed the following: a. The Plan of Care, dated 1/23/22 to 3/23/22, included orders for Invega Trinza 819 milligrams (mg) per 2.625 milliters (ml) with instructions to inject 2.625 ml intramuscular every 90 days for schizophrenia. b. An interim physician's order, dated 2/2/22, ordered to discontinue the current Invega Trinza dose and change to Invega Hafyera 1560 mg per 5 milliliters as directed.. The clinical record lacked documentation of a Plan of Care update including all patient care orders.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy review, other medical professional interviews and clinical record review, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 7 of 15 sampled patients with transfers/ discharges (Patients #1, #2, #3, #4, #7, #10 and #11). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: 6. Patient #1 had a start of care date of 3/6/2021 and was transferred to inpatient facility on 8/10/21. Clinical record review revealed: a. The update to the comprehensive assessment at the time of transfer to inpatient facility, dated 8/10/21, documented the agency was notified on 8/9/21 of the patient's admission to the hospital. The assessment was signed with an electronic signature date of completion on 8/11/21. b. The transfer summary was sent to the doctor on 8/13/21, 2 days late. 7. Patient #10 had a start of care date of 9/7/2021 and was discharged from agency services on 1/4/2022. Clinical record review revealed: a. The update to the comprehensive assessment at the time of discharge, dated 1/4/22, documented the patient's discharge date was 1/4/22 and the patient remained in the community without formal assistive services. The discharge assessment had an electronic signature date of completion of 1/16/22. b. The physician's interim order, dated 1/4/22, stated discharge from agency due to patient not wanting services. c. A client coordination note, dated 1/16/22 documented the patient was discharged from services due to continuing to refuse visits, staff unable to contact the patient, and the patient was noncompliant with Plan of Care. d. The home health discharge summary (auto-generated) documented the summary was sent to the physician on 1/27/22, 16 days late according to regulation and agency policy. The surveyors reviewed the above findings with agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey. 4. Patient #2 had a start of care date of 7/9/21 and was discharged from agency services on 8/27/21. The patient's clinical record included documentation of a Discharge Comprehensive Assessment, dated as initiated on 8/27/21. The patient's clinical record included documentation of a discharge summary sent to the physician after the patient's discharge. The discharge summary was sent on 9/7/21, 4 days late according to agency policy and regulation. 5. Patient #3 had a start of care date of 10/14/21 and discharge date of 2/21/22. The episode coordination notes included documentation of patient transfer for admission to a hospital on 11/1, 11/19/21 and 2/9/22. The patient's clinical record lacked documentation of a transfer summary completed and sent to the receiving hospital after the patient's admission. The agency failed to complete a transfer summary and send to the receiving hospital after patient admission. According to the agency policy, titled Transfer Summaries and dated 4/2018, the agency must complete the transfer summary within 48 hours and send the summary to the physician caring for the patient within 2 business days or within 2 business days of becoming aware of the transfer. According to the agency policy, titled Discharge Summaries and dated 4/2018, the agency must complete the discharge summary within 72 hours and send the summary to the patient's physician and any other professional who will be caring for the patient after discharge within 5 business days from the patient's discharge. 1. Patient #4 had a start of care date of 3/11/2021 and was discharged from agency services on 3/4/2022. Clinical record review revealed: The update to the comprehensive assessment at the time of discharge, dated 3/4/2022, documented the patient's discharge date was 3/4/2022 and the patient remained in the community without formal assistive services. The physician's interim order, dated 3/4/2022, stated "DC from agency on 3/3/2022" was sent to the physician. The home health discharge summary (auto-generated) documented the agency sent the summary to the primary care physician on 3/8/2022, 2 business days after the patient's discharge date. The summary indicated the patient was discharged from the agency as the local office was closing and another home health agency planned to admit the patient when able. During interview with a representative of another home health agency on 4/12/2022 at 3:40 PM, the agency admitted multiple patients from Careage Home Health due to the agency closing the local office. The representative confirmed they admitted Patient #4 on 3/10/2022. The agency provided no evidence the summary had ever been sent to the new home health agency. 2. Patient #7 had a start of care date of 10/13/2016 and was discharged from agency services on 3/11/2022. Clinical record review revealed: The update to the comprehensive assessment at the time of discharge, dated 3/11/2022, documented the patient's discharge date was 3/11/2022 and the patient remained in the community without formal assistive services. The physician's interim order, dated 3/11/2022, stated "patient discharged from agency" was sent to the physician. The home health discharge summary (auto-generated) lacked identification of who the summary was sent to and the date the summary was sent. During interview with a representative of another home health agency on 4/12/2022 at 3:40 PM, the agency admitted multiple patients from Careage Home Health due to the agency closing the local office. The representative confirmed they admitted Patient #7 on 3/11/2022. The agency provided no evidence the summary had ever been sent to the patient's primary care physician or the new home health agency. 3. Patient #11 had a start of care date of 12/15/2012 and was discharged from agency services on 2/25/2022. Clinical record review revealed: The update to the comprehensive assessment at the time of discharge, dated 2/25/2022, documented the patient's discharge date was 2/25/2022 and the patient remained in the community without formal assistive services. The physician's interim order, dated 2/25/2022, stated "DC from agency on 2/25/2022" was sent to the physician. The home health discharge summary (auto-generated) documented the agency sent the summary to the primary care physician on 3/9/2022, 8 business days after the patient's discharge date. During interview with a representative of another home health agency on 4/13/2022 at 9:53 AM, the agency admitted multiple patients from Careage Home Health due to the agency closing the local office. The representative confirmed they admitted Patient #11 on 2/28/2022. The agency provided no evidence the summary had ever been sent to the new home health agency.