Every finding on record at Grove Park Pharmacy Home Care, LLC

An onsite unannounced Emergency Preparedness Survey was conducted at Grove Park Pharmacy Home Care, LLC from 07/15/2024 to 07/17/2024. The home health agency is in substantial compliance with the Medicare Conditions at 42 CFR 484.102 (Establishment of the Emergency Program).

An unannounced onsite Recertification Survey was conducted at Grove Park Pharmacy Home Care, LLC from 07/15/2024 to 07/17/2024. The facility is in substantial compliance with the Medicare Conditions at 42 CFR PART 484 with Standard level deficiencies cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to complete the initial assessment visit either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner ordered start of care date for three of seven patient records reviewed, Patients #3 and #6. Findings: Review of Patient #3's record on 7/16/24 at 1:18 PM revealed Patient #3 was admitted to the Home Health Agency (HHA) on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar levels). The referral was dated 5/21/24 and faxed to the HHA on 5/23/24. The initial assessment was completed on 5/29/24 (six days after the referral was received). There was no documentation in the record indicating a reason for the delay in care. In an interview with the Clinical Director (CD) on 7/17/24 at 10:46 AM, she/he reviewed Patient #3's record and confirmed the findings stating, "No, she does not have a communication note in there for the delay or an order." Review of Patient #6's record on 7/16/24 at 12:07 PM revealed Patient #6 was admitted to the HHA on 3/12/24 with a diagnosis of Peripheral Vascular Disease (PVD). The referral for HHA services was dated 3/5/24. The initial assessment was completed on 3/12/24 (seven days after the referral date). There was no documentation in the record indicating a reason for the delay in care. In an interview with the CD on 7/17/24 at 9:18 AM, she/he reviewed Patient #6's record and confirmed the findings. Review of the HHA policy titled, "ADMISSION CRITERIA AND PROCESS" on 7/17/24 revealed, "...Home Care staff shall make the initial home visit within the time requested by the referral source or as ordered by the physician or per the patient/family requested date...goal is to admit patients within 48 hours after the referral/order...".

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 observation, interview and record review, the home health agency staff failed to provide and update the current medication list for 1 of 2 applicable patient records reviewed. (Patient #7). Findings include: Home observation on 07/16/24 from 10:40 AM to 11:40 AM showed Patient #7's hospice medication list with inaccuracies. Patient #7 stated taking Lasix 20 mg (milligrams) tablet by mouth once a day, Potassium 99 meq (milliequivalent) tablet by mouth once a day, Zinc 50 mg by mouth once a day at bedtime and Calcium Chews 650 mg 1 chew by mouth once a day of which none were listed on the home health agency medication list. During an interview on 7/17/24 at 10:15 AM, the Clinical Director verified the findings.

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 interview and record review, the home health agency failed to include re-hospitalization risk assessments and parameters for glucose reporting in the Plan of Care (POC) for 6 out of 7 patients (Patient #1, #2, #3, #5, #6 and #7). Findings: Review of Patient # 1's record on 7/15/24 at 1:19 PM revealed Patient #1 was admitted to the Home Health Agency (HHA) on 5/30/24 with a diagnosis of a fractured pelvis. The plan of care dated 5/30/24 to 7/28/24 did not include documentation of the risk for re-hospitalization. In an interview with the Clinical Director (CD) on 7/17/24 at 9:25 AM she/he reviewed Patient #1's record and plan of care and confirmed the findings. Review of Patient #3's record on 7/16/24 at 1:18 PM revealed Patient #3 was admitted to the HHA on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar). The plan of care dated 5/29/24 to 7/27/24 did not include documentation of the risk for re-hospitalization. Additionally, review of the nursing visit notes dated 5/29/24, 6/7/24, 6/10/24, 6/20/24, 6/26/24 and 7/2/24 revealed Patient #3's blood sugars were monitored each nursing visit and ranged from 100 to 309. There was nothing in the plan of care indicating parameters for blood sugar levels to be reported to the physician. In an interview with the CD on 7/17/24, she/he reviewed Patient #3's record and confirmed the findings and confirmed the plan of care should include blood sugar parameters indicating when to notify the physician. Review of Patient #4's record on 7/16/24 at 2:41 PM revealed Patient #4 was admitted to the HHA on 5/29/24 with a diagnosis of Diabetes with a foot ulcer (wound). Review of the nursing visit notes dated 5/30/24, 6/3/24, 6/7/24, 6/10/24, 6/14/24, 6/19/24, 6/26/24, 7/3/24, and 7/10/24 revealed Patient #4's blood sugars were monitored each nursing visit and ranged from 80 to 200. Review of the plan of care for the period 5/29/24 to 7/27/24 revealed there was no indication of parameters for blood sugar levels to be reported to the physician. In an interview with the CD on 7/17/24 at 10:07 AM, she/he reviewed Patient #4's record and confirmed the findings. Review of Patient #6's record on 7/16/24 at 12:07 PM revealed Patient #6 was admitted to the HHA on 3/12/24 with a diagnosis of Peripheral Vascular Disease (PVD) and Diabetes. Review of the plan of care dated 3/12/24 to 5/10/24 revealed no documented risk for re-hospitalization. Additionally, review of the nursing visit notes dated 3/21/24, 3/25/24, and 3/28/24 revealed Patient #6's blood sugars were monitored each nursing visit. Review of the plan of care for the period 3/12/24 to 5/10/24 revealed no parameters for blood sugar levels to be reported to the physician. In an interview with the CD on 7/17/24 at 9:21 AM, she/he reviewed Patient #6's record and confirmed the findings. Findings include Review of Patient # 2's record on 07/16/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 07/09/24 with a diagnosis of spinal stenosis, lumbar region without neurogenic claud. The POC dated 07/09/24 to 09/06/24 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 9:25 AM Clinical Director reviewed Patient #2's record and plan of care and confirmed the findings. Review of Patient # 5's record on 07/15/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 05/22/23 with a diagnosis of Encounter for change or removal of surgical wound dressing. The POC dated 05/22/23 to 07/20/23 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 1:35 PM, Clinical Director reviewed Patient #5's record and plan of care and confirmed the findings. Review of Patient # 7's record on 07/16/24 at 2:03PM revealed Patient #7 was admitted to the HHA on 05/31/24 with a diagnosis of Unspecified fracture of fourth lumbar vertebra, sequela. The POC dated 05/31/24 to 07/29/24 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 10:15 AM, Clinical Director reviewed Patient #7's record and plan of care and confirmed the findings. Findings include Review of Patient # 2's record on 07/16/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 07/09/24 with a diagnosis of spinal stenosis, lumbar region without neurogenic claud. The POC dated 07/09/24 to 09/06/24 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 9:25 AM Clinical Director reviewed Patient #2's record and plan of care and confirmed the findings. Review of Patient # 5's record on 07/15/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 05/22/23 with a diagnosis of Encounter for change or removal of surgical wound dressing. The POC dated 05/22/23 to 07/20/23 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 1:35 PM, Clinical Director reviewed Patient #5's record and plan of care and confirmed the findings.

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 record review and interview, the Home Health Agency (HHA) failed to ensure physician's orders were documented in the clinical record for two of seven patient records reviewed, Patients #1 and #3. Findings include: Review of Patient #1's record on 7/15/24 at 1:19 PM revealed Patient #1 was admitted to the HHA on 5/30/24 with a diagnosis of a fractured pelvis. The nursing visit note dated 7/9/24 indicated, "...Labs...Blood test obtained...Visit Narrative...RN TO HOME FOR...LAB DRAW...LABS OBTAINED...". The nursing visit note dated 7/17/24 indicated, "...Visit Narrative...RN TO HOME FOR...lab draw...". Review of the plan of care dated 5/30/24 to 7/28/24 and review of the physician's orders revealed no physician's order for labs to be drawn for Patient #1. In an interview with the Clinical Director (CD) on 7/17/24 at 10:36 AM, she/he reviewed Patient #1's record and confirmed the findings stating, "I don't see an order." Review of Patient #3's record on 7/16/24 at 1:18 PM revealed Patient #3 was admitted to the HHA on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar levels). Review of the nursing visit notes dated 5/29/24, 6/10/24, 6/20/24 and 6/26/24 revealed the nurse performed wound care to Patient #3's left foot wound. Review of the plan of care dated 5/29/24 to 7/27/24 and the physician's orders revealed no physician's order for wound care to Patient #3's left foot wound. Review of the HHA policy titled, "HOME HEALTH PLAN OF CARE" on 7/17/24 revealed, "...All home care services are furnished under a physician's order, based on the patient's plan of care...".

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure services were only provided as ordered by a physician or allowed practitioner for two of seven records reviewed for physician's orders, (Patient #5 and Patient #6). Findings: Review of Patient #6's record on 7/16/24 at 12:07 PM revealed Patient #6 was admitted to the HHA on 3/12/24 with a diagnosis of Peripheral Vascular Disease (PVD) and Diabetes (elevated blood sugar levels). The plan of care dated 3/12/24 to 5/10/24 indicated, "...Orders for Disciplines and Treatment...SN [Skilled Nurse] Frequency...1w9 [one time a week for nine weeks]...Effective Date...3/12/24." Review of the nursing visit notes revealed a nurse made a PRN visit on 3/28/24. There was no physician's order for any PRN (as needed nursing visits) and no documentation indicating why the PRN visit was done. In an interview with the CD on 7/17/24 at 9:20 AM, she/he reviewed Patient #6's record and confirmed the findings. Review of the HHA's policy titled, "PHYSICIANS ORDERS" on 7/17/24 revealed, "...All home care services are provided in accordance with physician orders..." Review of Patient #5's medical record on 7/15/24 at 12:07 PM revealed Patient #5 was admitted to the HHA on 05/22/23 with a diagnosis of Encounter for change or removal of surgical wound dressing. The plan of care dated 05/22/23 to 07/20/23 reports Skilled Nurse (SN) schedule 3 visits every week for 9 weeks with 5 visits Pro Re Nata (PRN) starting 05/22/24. Physician orders dated 07/03/23 reports SN schedule decreased to 2 visits a week for 2 weeks starting 07/05/23. SN visits are documented on 07/10/23, 07/13/23 and 07/14/23. There are no orders for the visit on 07/14/23. During an interview on 07/17/24 at 1:35 PM, Clinical Director reviewed Patient #5's record and plan of care and confirmed the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Home Health Agency (HHA) failed to ensure Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) provided services as indicated in the plan of care and physician referral for two of seven patient records reviewed, (Patient #2 and Patient #4). Review of Patient #4's record on 7/16/24 at 2:41 PM revealed Patient #4 was admitted to the Home Health Agency (HHA) on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar levels) with a foot ulcer (wound). The plan of care dated 5/29/24 to 7/27/24 indicated, "..Orders for Discipline and Treatment...Notify Physician of vital sign parameters out of range...Systolic BP (blood pressure; SBP) Greater Than (>) 160..." Review of the nursing visit notes revealed on 6/19/24 Patient #4's SBP was 168 and on 6/26/24 his/her SBP was 162. There was no documented evidence the physician was notified Patient #4's SBP was greater than 160. In an interview with the Clinical Director (CD) on 7/17/24 at 10:07 AM, she/he reviewed Patient #4's record and confirmed the findings. Findings included Review of Patient #2’s medical record on 07/16/24 at 1:40 PM showed referral orders for OT evaluation. There is no documentation in the medical record for why OT assessment was not completed. PT visit schedule on the POC is 2 visits a week for 4 weeks starting 05/31/24, there are no documented PT visits the week of 05/31/24. During an interview on 07/17/24 at 10:35 AM, Clinical director stated that the home health does not have an OT. Clinical director stated that there should have been documentation in the chart that the physician and patient were both notified and that the PT should have clarified the visit schedule to start the week of 06/02/24.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to complete a supervisory assessment of the aide services being provided no less frequently than every 14 days for one of one patient records reviewed receiving aide services, Patient #1. Findings include: On 7/16/24 at 9:35 AM a home visit by Aide #1 to Patient #1 was observed. Patient #1 stated the HHA Aide visited her/him two times every week. Review of Patient #1's record on 7/16/24 at 1:19 PM revealed the HHA Aide visited on 5/7/24, 5/14/24, 7/5/24, 7/9/24 and 7/12/24. There was no documented evidence the HHA Aide services were supervised. In an interview with the Clinical Director (CD) on 7/17/24 at 10:44 AM, she/he reviewed Patient #1's record and confirmed the findings. Review of the HHA policy titled, "HOME HEALTH AIDE SERVICES" on 7/17/24 revealed, "...Supervision of In-Home Aides...a supervisory visit is made to the home of all patients at the following minimums...At least every fourteen (14) days and more frequently if indicated by the patient's condition...".

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure laboratory results from blood draws by the HHA Nurse were in the patients clinical record for one of one patients reviewed for laboratory tests, Patient #1. Findings include: Review of Patient #1's record on 7/15/24 at 1:19 PM revealed Patient #1 was admitted to the HHA on 5/30/24 with a diagnosis of a fractured pelvis. Review of the nursing visit notes revealed the HHA Nurse drew blood for laboratory analysis on 7/9/24 and 7/17/24. There was no documentation in the record of the laboratory results. In an interview with the Clinical Director (CD) on 7/17/24 at 10:40 AM, she/he reviewed Patient #1's record and confirmed the findings.

An on-site initial Emergency Preparedness Program (EP) survey was conducted at Grove Park Pharmacy Home Care from 11/29/2021 to 12/2/2021. Grove Park Pharmacy Home Care is in substantial compliance with the Medicare Conditions at 42 CFR 484.102 (Establishment of the Emergency Program). The following standard level deficiencies were identified during the survey.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide a policy within the agency’s Emergency Preparedness Plan (EPP) for staffing in an emergency. On 12/2/2021 at 10:16 AM, a review of the agency’s EPP reveals no policy for staffing in an emergency. This finding is verified by the Administrator at 10:16 AM on 12/2/2021.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency staff failed to provide measurable goals for all goals listed on the Plan of Care (POC) in six out of seven patient records reviewed (Patient #1- #6). Patient #3 On 11/30/2021 at 2:34 PM, a review of Patient #3’s chart reveals the POC for the certification period dated 9/29/2021 to 11/27/2021 does not have measurable goals for all goals listed (measures to prevent skin breakdown and Physical Therapy evaluation). The Resumption of Care POC has the same non-measurable goals listed. This finding is verified by the Clinical Manager and Physical Therapist at 4:31 PM on 12/1/2021. Patient #1 On 12/1/2021 at 9:53 AM, a review of Patient # 1’s chart reveals the POC for the certification period of 9/26/2021 to 11/24/2021 does not contain measurable goals for all goals (attain optimal effectiveness of pain and demonstrate understating of the emergency preparedness plan). The Resumption of Care POC has the same goals which are not measurable. This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 3:56 PM. Patient #2 On 12/1/2021 at 11:03 AM, a review of Patient 2’s chart reveals the POC for the certification period of 10/2/2021 to 12/10/2021 does not contain measurable goals for all goals (Physical Therapy evaluation will be performed and will demonstrate improved muscle function). The Resumption of Care POC also has non-measurable goals (demonstrate measures to prevent skin breakdown, a Physical Therapy evaluation, and improved muscle function). This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 4:24 PM. Patient #4 On 12/1/2021 at 11:57 AM, a review of Patient #4’s chart reveals non-measurable goals are listed on the POC (performing blood sugar checks and teach diabetic signs). This finding is verified by the Clinical Manager and Physical Therapist at 4:41 PM on 12/1/2021. Patient #5 On 12/1/2021 at 12:34 PM, a review of Patient #5’s chart reveals the POC for the certification period dated 11/8/2021 to 1/6/2022 has goals which are not measurable (Physical Therapy evaluation). This finding is verified by the Clinical Manager and the Physical Therapist at 4:01 PM on 12/1/2021. Patient #6 On 12/1/2021 at 12:55 PM, a review of Patient # 6’s chart reveals the POC for the certification period dated 6/29/2021 to 8/27/2021 has goals which are not measurable (propel wheelchair). This finding is verified by the Clinical Manager and the Physical Therapist at 4:12 PM on 12/1/2021.

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 record review and interview, the agency staff failed to provide a Plan of Care (POC) that contained all required components in seven out of seven patient records reviewed (Patient #1 - #7). Patient #3 On 11/30/2021 at 2:34 PM, a review of Patient #3’s chart reveals the POC for the certification period dated 9/29/2021 to 11/27/2021 does not contain information regarding functional limitations, nutritional requirements, activities permitted and rehospitalization risk. The Resumption of Care for the same certification period does not contain information regarding rehospitalization risk. This finding is verified by the Clinical Manager and Physical Therapist at 4:31 PM on 12/1/2021. Patient # 1 On 12/1/2021 at 9:53 AM, a review of Patient # 1’s chart reveals the POC for the certification period of 9/26/2021 to 11/24/2021 does not contain information regarding advanced directives and rehospitalization risk. The Resumption of Care POC does not contain information for mental, cognitive, advanced directives, and risk for rehospitalization. This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 3:56 PM. Patient #2 On 12/1/2021 at 11:03 AM, a review of Patient 2’s chart reveals the POC for the certification period of 10/2/2021 to 12/10/2021 does not have information related to rehospitalization risks and it is missing from the Resumption of Care POC also. This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 4:5 PM. Patient #4 On 12/1/2021 at 11:57 AM, a review of Patient #4’s chart reveals the POC for the certification period dated 10/7/2021 to 12/5/2021 does not have information related to rehospitalization risks and safety. This finding is verified by the Clinical Manager and the Physical Therapist at 4:41 PM on 12/1/2021. Patient #5 On 12/1/2021 at 12:34 PM, a review of Patient #5’s chart reveals the POC for the certification period dated 11/8/2021 to 1/6/2022 does not have rehospitalization risks documented. This finding is verified by the Clinical Manager and the Physical Therapist at 4:01 PM on 12/1/2021. Patient #6 On 12/1/2021 at 12:55 PM, a review of Patient # 6’s chart reveals the POC for the certification period dated 6/29/2021 to 8/27/2021 does not have Advanced Directive information or rehospitalization risks listed. This finding is verified by the Clinical Manager and the Physical Therapist at 4:12 PM on 12/1/2021. Patient #7 On 12/1/2021 at 1:13 PM, a review of Patient # 7’s chart reveals the POC for the certification period dated 7/27/2021 to 9/24/2021 does not rehospitalization risks listed. This finding is verified by the Clinical Manager and the Physical Therapist at 3:50 PM on 12/1/2021.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Skilled Nurse (SN) failed to follow orders on the Plan Of Care (POC) regarding weights, notification of the Physician for data outside of ordered parameters, and obtaining vital signs in three out of seven chart reviewed (Patient #2, Patient #4, and Patient #5). Patient #2 On 12/1/2021 at 11:03 AM, a review of Patient 2’s chart reveals Resumption of Care Plan of Care (POC) has orders to weigh patient each visit and notify the physician for a five-pound weight gain. The Resumption of Care Skilled Nurse (SN) visit on 11/19/2021 reveals documentation by the SN the weight could not be assessed with no reason documented. There is no documentation the physician was notified or any other method of obtaining a baseline weight. On 11/23/2021 the SN documents a weight of 340 pounds. On the SN visit dated 11/26/2021, no weight is documented. On 11/30/2021 visit, the SN documents a weight of 351 pounds. There is no documentation the physician was notified for the weight increase from 11/23/2021. This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 4:24 PM. Patient #4 On 12/1/2021 at 11:57 AM, a review of Patient #4’s chart reveals physician orders to monitor weight loss. On 10/7/2021 the Skilled Nurse (SN) documents a weight of 176 pounds. On SN visits 10/21/2021, 11/4/2021, 11/11/2021, 11/18/2021, and 11/26/2021 have no weights documented. The orders have parameters for abnormal ranges of heart rate, temperature, oxygen saturation, respirations, pain level, and blood pressure. The SN visit dated 10/21/2021 has no vital signs documented. The SN visit for 11/4/2021 has a blood pressure documented as 160/100 millimetre of mercury (mmHg). There is no documentation of the physician being notified of the blood pressure outside of the parameters given. (The diastolic parameter to notify the physician is if greater than 90 mmHg.)There is no documentation of the physician being notified. This finding is verified by the Clinical Manager and Physical Therapist at 4:41 PM on 12/1/2021. Patient #5 On 12/1/2021 at 12:34 PM, a review of Patient #5’s chart reveals the POC for the certification period dated 11/8/2021 to 1/6/2022 has a primary diagnosis of Type 2 Diabetes Mellitus, without complications. The orders contain abnormal parameters for the SN notify the physician for heart rate, temperature, respirations, pain level, oxygen saturation, and blood pressure. The SN visit for 11/25/2021 does not document heart rate, blood pressure, and oxygen saturation levels are not documented for this visit. This finding is verified by the Clinical Manager and the Physical Therapist at 4:01 PM on 12/1/2021.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency staff failed to update the Plan of Care (POC) during the certification period in three out seven patient records reviewed (Patient #1, #2, and #5). Patient #1 On 12/1/2021 at 9:53 AM, a review of Patient # 1’s chart reveals the POC for the Resumption of Care for the certification period of 9/26/2021 to 11/24/2021 was not updated after the reversal of a colostomy. The POC orders state to perform and teach the patient ostomy care and how to change the wafer/bag every visit and to instruct the patient on management of the colostomy including stoma care. This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 3:56 PM. Patient #2 On 12/1/2021 at 11:03 AM, a review of Patient 2’s chart reveals the Resumption of Care POC for the certification period of 10/2/2021 to 12/10/2021 was not updated to show the primary diagnosis as Acute systolic (congestive) heart failure but shows the principal diagnosis as cellulitis of right lower limb. This finding is verified by the Clinical Manager and Physical Therapist on 12/1/2021 at 4:24 PM. Patient #5 On 12/1/2021 at 12:34 PM, a review of Patient #5’s chart reveals the POC for the certification period dated 11/8/2021 to 1/6/2022 has a primary diagnosis of Type 2 Diabetes Mellitus, without complications. The orders do not contain parameters for the SN to notify the physician regarding abnormal blood glucose levels. This finding is verified by the Clinical Manager and the Physical Therapist at 4:01 PM on 12/1/2021.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide a Clinical Manager’s availability during all operating hours of the agency due to the Clinical Manager’s 0.5 Full-Time Equivalent (FTE) responsibility to another agency located within the same office space. On 12/2/2021 at 10:00 AM, a review of the employee list with allotted FTEs for each employee reveals the agency has a Clinical Manager allotment of 0.5 FTE. The home care agency is currently located in the same office as another agency and the same clinical manager works for the other agency 0.5 FTE of time. This finding is verified by the Administrator on 12/2/2021 at 10:00 AM.