Every finding on record at Guthrie County Public Health Nursing Service

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 8/5/24 through 8/7/24, the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 8/5/24 through 8/7/24. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 73 patients at the time of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on review of employee personnel files and staff interview, the hospice failed to ensure 1 of 2 sampled home health aides (Staff D) satisfactorily demonstrated competency on the written skills examination prior to the home health aide providing services to patients. The home health agency employed 4 home health aides at the time of the survey. Failure to ensure home health aides have successfully completed a competency evaluation program increased the risk for patients to receive inadequate or inappropriate care. Findings include: Staff D, Home Health Aide, had a hire date of 3/27/23. Staff D's personnel file lacked documentation a Registered Nurse (RN) had administered and reviewed the written competency test, dated 4/4/23. On 8/7/24 at 10:00 AM, during an interview, the Director of Finance and Quality confirmed the written examination lacked a signature identifying an RN had administered and reviewed the written competency test. The above information was reviewed with the Administrator, Director of Finance and Quality, Staff C, Registered Nurse (RN), Staff E, RN, Staff F, RN and Staff G, RN.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, staff and patient interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patients #3 and #5). Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: According to the agency policy, dated 10/5/22, titled Home Health Aide: Assignment, any change in the assignment must be approved by the professional managing the client's care. The client/caregiver will be notified of all changes. 1. Patient #3 had a start of care date of 4/15/24. a. The Plans of Care (POCs), dated 4/15/24 to 6/13/24 and 6/14/24 to 8/12/24, included physician orders for skilled nursing services for assessment every week and home health aide services 1-2 times per week to assist with personal care. a. The Aide Care Plan, dated 6/13/24, included the following assigned tasks: assist with transfer in/out of shower as requested, light housekeeping pull up bath mat/rinse shower/drape towel, assist dress upper/lower body as requested, comb hair assist as requested, shampoo hair each visit, skin care lotion as requested, shower each visit, universal precautions each visit, deodorant each visit, desitin to bottom as requested, assist with sock/shoes as requested and weight each visit-may refuse if not wearing prothesis. b. Home health aide visit notes, dated 6/4, 6/7, 6/11, 614, 6/18, 6/21, 6/25, 6/28, 7/2, 7/5, 7/9, 7/12, 7/16, 7/19, 7/23, 7/26, 7/30 and 8/2/24, included documentation the patient weight taken with no documentation of weight results. c. During an interview on 8/6/24 at 8:30 AM the patient stated he/she had not requested the home health aide take his/her weight and also stated the home health aide never asked him/her to obtain the patient's weight. The home health aide failed to provide services that are ordered by the physician, included in the plan of care. 2. Patient #5 had a start of care date of 6/10/24. a. The POC, dated 6/10/24 to 8/8/24, included physician orders for skilled nursing services for assessment every other week and home health aide services 2 times per week to assist with personal care. a. The Aide Care Plan, dated 6/10/24, included the following assigned tasks: change linen per request, tidy bathroom q visit, pull up bathmat, assist dress upper body every visit, comb hair every visit, nail care fingernails per request, shampoo hair every visit, shave every visit, skin care-lotion per request, shower every visit, universal precautions every visit, assist dressing lower body every visit, assist with socks and shoes every visit, light housekeeping tasks and clean bathroom weekly. b. Home health aide visit notes, dated 6/12, 6/17, 6/20, 6/24, 6/26, 7/1, 7/3, 7/8, 7/11, 7/15, 7/18, 7/22, 7/25, 7/29 and 8/1/24, included documentation the home health aide completed the task of clean the bathroom 2 times a week. The home health aide failed to provide services as ordered by the physician, included in the plan of care. The above stated findings were reviewed with the Administrator, Staff C, RN, Staff E, RN, Staff F, RN, Staff G, RN and the Director of Finance and Quality.

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 observations, agency staff interviews, record review and policy review, the agency failed to send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 2 of 2 sampled patients discharged from the agency. ( Patient #6 and #7) 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: 2. Patient #7 had a start of care date of 10/17/23 and a discharge date of 1/25/24. Clinical record review revealed the following: a. The Plan of Care, dated 10/17/23 to 12/15/23 and 12/16/23 to 2/13/24, included orders for skilled nursing services and home health aide services. b. The discharge order, dated 1/25/24, included information of the patient's discharge date, physician responsible for the home health plan of care, reason for admission, discharge condition and outcomes in meeting the goals in the plan of care. The discharge order lacked discharge summary requirements including the following: admission date, medications the patient had been taking at discharge, the type and frequencies of all services provided and teaching provided to the patient and caregiver. c. The clinical record lacked evidence, a discharge summary completed and sent to the physician. The agency failed to complete a thorough discharge summary to send to the physician within 5 days of discharge. The above stated findings shared with the Administrator, Staff C, RN, Staff E, RN, Staff F, RN, Staff G, RN and the Director of Finance and Quality. According to the policy, Client Discharge Process, dated 10/15/22, a completed discharge summary will be sent to the primary care practitioner, or other health care professional who will be responsible for providing care and services to the client after discharge, within 5 days of the discharge. 1.Patient #6 had a start of care date of 3/9/24 and a discharge date of 6/7/24. a. During an interview on 8/6/24 at 3:30 PM, with Staff H, Director of Finance and Quality, stated the software the agency is currently using does not have the option of creating a discharge summary with the required components, staff instructed to add a summary to the discharge order, which is signed by the physician. b. During an interview on 8/7/24 at 8:45 AM, with Staff C, Registered Nurse, the agency does not complete a separate discharge summary, but instead will write a brief summary on the discharge order that is sent to the physician upon discharge. Clinical record review revealed the following: c. The Plan of Care, dated 3/9/24-5/27/24, and 5/28/24 - 7/26/24 included orders for skilled nursing services, physical therapy, occupational therapy and home health aide services. d. The discharge order sent to the physician, dated 6/7/24, included information of the patient's discharge date, physician responsible for the home health plan of care, reason for admission, discharge condition and outcomes in meeting the goals in the plan of care. The discharge order lacked the summary requirements including: admission date, medications patient was taking at discharge, and type and frequencies of all services provided. e. The clinical record lacked evidence, a discharge summary was completed and sent to the physician. The agency failed to complete a thorough discharge summary to send to the physician within 5 days of discharge.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on observation, agency staff interviews, clinical record review and policy review, the agency failed to ensure agency staff properly authenticated all clinical entry notes and/or completed within the agency's expected timeframe for 6 of 7 sampled patients( Patient #1, #2, #3, #5 #6, and #7). Failure to ensure all clinical record documentation was dated, timed and signed with staff title and/ or completed within the agency's expected timeframe, increased the risk of ineffective communication between staff members providing services to its patients. 4. Patient #3 had a start of care date of 4/14/24. Clinical record review revealed the following: a. The POC, dated 6/14/24 to 8/12/24, included physician orders for skilled nursing and home health aide services. b. The home health aide notes signed by Staff I, Home Health Aide, dated 6/14, 6/18, 6/21, 6/25, 7/2 and 7/30/24, lacked a title next to the signature. The agency failed to include the home health aide title in the electronic signature. 5. Patient #5 had a start of care date of 6/12/24. Clinical record review revealed the following: a. The POC, dated 6/10/24 to 8/8/24, included physician orders for skilled nursing and home health aide services. b. The home health aide notes signed by Staff I, Home Health Aide, dated 6/12, 6/17, 6/20, 6/24, 6/26, 7/1, 7/3, 7/8, 7/11, 7/15, 7/18, 7/22, 7/25, 7/29 and 8/1/24, lacked a title next to the signature. The agency failed to include the home health aide title in the electronic signature. 6. Patient #7 had a start of care date of 10/17/24 and discharge date of 4/3/24. Clinical record review revealed the following: a. The POC, dated 12/16/23 to 2/13/24, included physician orders for skilled nursing and home health aide services. b. The home health aide notes signed by Staff C, Registered Nurse, dated 12/5, 12/12 and 12/21/24, lacked a title next to the signature. The agency failed to include the Registered Nurse title in the electronic signature. The above stated findings shared with the Administrator, Staff C, RN, Staff E, RN, Staff F, RN, Staff G, RN and the Director of Finance and Quality. 3.Patient #2 had a start of care date of 6/30/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/9/24 to 8/7/24 included physician orders for skilled nursing and home health aide services. b. The home health aide notes signed by Staff D, dated 7/5/24, 7/22/24 and 8/2/24 lacked credentials. Agency staff failed to appropriately authenticate the clinical record documents. According to the policy , clinical documentation, dated 10/2022, all routine notes are completed, signed and locked within 24 hours of the visit. 1. Patient #1 had a start of care date of 6/21/24 Clinical record revealed the following: a. The plan of care, dated 6/21/24 to 8/19/24, included physician orders for skilled nursing. a. The routine skilled nursing note dated 8/2/24, was not created or signed as completed until 8/6/24, 3 days late according to the agency's policy. The agency failed to complete and sign, electronic skilled nursing note timely based on the agency's policy. According to the policy, Clinical Documentation, dated 10/2022, a separate note will be completed for each visit and signed and dated by the appropriate personal. 2. Patient #6 had a start of care date of 3/9/24. Clinical Record Revealed the Following: a. The Plan of care, dated 03/29/2024 to 05/27/2024, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. a. The initial Physical Therapy Evaluation, dated 4/3/24, included a digital signature, but lacked credentials. b. The routine Physical Therapy visit notes dated, 4/30/24 and 5/6/24, included a digital signature, but lacked credentials. c. The home health aide routine visit notes, dated 4/3/24, 4/5/24 ,4/8/24, 4/15/524, 4/19/24, and 4/22/24, included a digital signature, but lacked credentials. Agency staff failed to appropriately authenticate the clinical record documents.

The recertification survey, dated 10/11/2021 through 10/13/2021, identified the home health agency was found to be in substantial compliance in relation to emergency preparedness regulations.

After the rollout of the Internet Quality Improvement and Evaluation System (IQIES) for home health agencies, the IQIES functionality for this survey findings did not allow the state agency to send this document to your agency until today, December 21, 2021. The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 10/11/2021 through 10/13/2021. The Department found the agency to be in substantial compliance in relation to CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the agency operating out of compliance with the following standard level home health regulations:

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 clinical record review, policy review and staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral, within 48 hours of the of the agency's knowledge of the patient's return home from an inpatient facility or on the physician ordered start of care date for 2 of 6 sampled patients (Patients #5 and #7). The agency reported a current census of 61 patients. Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: Review of the agency policy, titled Initial Patient Comprehensive Assessment, dated 5/2018, revealed agency staff will conduct an initial visit with the patient within 48 hours of referral or on the physician ordered start of care date. 1. Patient #5 had a start of care date of 2/22/21 and transferred from agency services on 8/12/21. Review of the clinical record revealed the following: a. The initial comprehensive assessment, dated 2/22/21, included documentation the patient discharged from the hospital on 2/18/21 and agency staff received the referral on the patient on 2/19/21. The assessment included documentation which identified a physician did not give an order for a specific start of care date. b. The clinical record lacked documentation of any skilled nursing visits or initial assessment prior to the skilled nursing visit, dated 2/22/21. The clinical record lacked documentation of communication or a physician order to delay the start of care . On 10/13/21 at 1:22 PM, during an interview, the Clinical Manager agreed to look for any documentation including a physician order to delay the start of care. On 10/13/21 at 2:23 PM, during an interview, the Clinical Manager reported an inability to find any documentation or physician order to delay the start of care. Agency clinical staff failed to conduct an initial assessment visit within 48 hours of the referral to the agency. 2. Patient #7 had a start of care date of 2/1/21 and discharged from agency services on 9/27/21. Review of the clinical record revealed the following: a. A scanned fax referral form in the agency's electronic medical record (EMR) from an inpatient facility, dated and faxed 1/28/21, which included a history and physical and a referral for home health services. b. The initial comprehensive assessment, dated 2/1/21, included documentation the patient discharged from the hospital on 1/28/21 and agency staff received the referral on the patient on 2/1/21. The assessment included documentation which identified a physician did not give an order for a specific start of care date. c. The clinical record lacked documentation of any skilled nursing visits or initial assessment prior to the skilled nursing visit, dated 2/1/21. The clinical record lacked documentation of communication or a physician order to delay the start of care. On 10/12/21 at 3:30 PM, during an interview, the Clinical Manager agreed to look for information on why the patient did not receive an initial assessment visit within 48 hours of referral. On 10/13/21 at 12:53 PM, the surveyor received a written letter from the Clinical Manager with an explanation, dated 10/13/21. She responded in the letter by stating the agency did not receive the referral until the day after the patient discharged. Agency staff did not feel the patient was appropriate from home health services due to non-compliance with medications, blood sugars and the patient's risk for re-hospitalization. The Clinical Manager explained she contacted the social worker from the inpatient facility who apologized for sending the referral knowing how the agency staff felt about readmitting the patient. The Clinical Manager felt obligated to accept the patient since the patient had already been discharged and thought the agency would be providing services. The Clinical Manager reported she asked the inpatient social worker, if it was okay to wait and see the patient the following week to admit to services. According to the Clinical Manager, the social worker did get the okay from the discharging physician to admit the patient the following week. The Clinical Manager also responded in the letter by stating, "the order was never written, and this wasn't documented on a referral form." On 10/13/21 at 1:20 PM, during an interview, the Clinical Manager confirmed the information in the letter and reported there was no documentation in the clinical record to support this information. On 10/13/21 at 2:22 PM, during an interview, the Clinical Manager reported an inability to print the faxed referral information in the EMR. She agreed the faxed document indicated the inpatient facility sent the referral request to the agency on 1/28/21. Agency clinical staff failed to conduct an initial assessment visit within 48 hours of the referral to the agency. The Clinical Manager received the above findings and agency staff provided no further information prior to the end 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 clinical record review, agency policy review, home visit observation and staff interview, the facility failed to accurately complete a drug regimen review, including completion of all required components within the required time frames as part of the comprehensive assessment for 5 of 8 records reviewed (Patients #2, #3, #4, #6 and #8). The agency reported a census of 61 patients at the time of the survey. 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: " ". Patient #1 had a start of care date of 10/09/19. Clinical record review revealed the following: a. The Plans of Care, dated 9/28/2021 to 11/26/2021 and 7/30/2021 to 9/27/2021 included physician orders for the following medications: Warfarin, Furosemide, Potassium, Amlodipine, Benzonatate, Montelukast, Loratadine, Miralax, Dulcolax, Magnesium, Albuterol-Ipatropium, Aspirin, Atorvastatin, Budesonide, Clotrimazole, Fluticasone, Guaifenesin, Losartan, Metamucil, Omeprazole, Preservision and Propranolol. The same plan of care identified medication review/reconciliation and potential clinically significant issues will be resolved on admission, re-certs, and as problems identified. b. Skilled Nurse Comprehensive assessment completed at the recertification, dated 9/27/2021, included documentation a drug regimen review (DRR) was completed and the patient was compliant in taking medications. The DRR lacked documentation of drug reactions, ineffective drug therapy, significant drug interactions and duplicate drug therapy, required elements of the DRR. c. On 10/11/2021 at 1:30 PM, during an home visit observation with Staff E. RN (registered nurse), the Patient Medication Sheet printed 10/11/2021 identified current medications. Furosemide 20 mg 1 time daily dated 10/16/2019 and Furosemide 40 mg 1 time daily dated 11/26/2020. Potassium Chloride 20 MEQ (milliequivalants) 2 times daily dated 10/9/2019 and Potassium Chloride 20 MEQ dated 11/26/2020. The medication observed in the home identified Furosemide 40 mg 1 tab daily in the morning, 1 tab at noon prn (as needed) and 1 tab prn, dated 8/30/2021. Potassium 20 MEQ 1 tab 2 times daily and 1 tab prn when taking additional Furosemide dose prn. The agency failed to identify current physician orders. " ". Patient #3 had a start of care date of 6/08/2021. Review of the clinical record revealed the following: a. The Plans of Care, dated 10/06/2021 to 12/04/2021 and 8/07/2021 to 10/05/2021 included physician orders for the following medications: Fish oil, Meclizine, Unisom, Pantoprazole, Senna, Imoduim, Acetaminophen, Alprazolam, Calcium plus D, Clopidogrel, Losartan, Metoprolol, Miralax, Pepto Bismol, Potassium Chloride, Ropinirole and Simvastatin. Medication review/reconciliation and potential clinically significant issues will be resolved on admission, re-certs, and discharge. The same plan of care included physician orders for the following medications with duplicate therapeutic purposes: Senna and Miralax to treat constipation, Losartan and Metoprolol to treat hypertension. b. Skilled Nurse Comprehensive assessment completed at the recertification, dated 10/01/2021, included documentation a drug regimen review (DRR) was completed. The DRR lacked documentation of adverse effects, drug reactions, ineffective drug therapy, side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy, required elements of the DRR. The DRR failed to identify duplicate therapeutic medications taken by the patient. Review of the agency policy, titled Medication List and Monitoring, revealed a registered nurse (RN) is responsible for coordinating the efforts of monitoring the medication regimen. The RN will monitor medications for any potential adverse effects, ineffective drug therapy, significant drug interactions, duplicate drug therapy and noncompliance and will document the changes in the drug regimen at least every 60 days. Review of the agency policy, titled OASIS (Outcome and Assessment Information Set) Assessment, dated 6/24/2018, revealed agency nurses will complete a review of the patient's medications as part of the comprehensive assessment at start of care, every 60 days from the start of care and within 48 hours of returning home from an inpatient admission. The drug regimen review will include a review of all medications including over the counter, dietary supplements and homeopathic remedies. 2. Patient #2 had a start of care date of 8/19/21. Clinical record review, home visit observation and associated patient and agency staff interviews revealed the following: a.The Plan of Care, dated 8/19/2021 to 10/17/2021, included physician orders for skilled nursing and home health aide services and ordered Calcium Carbonate 600 mg with Vitamin D3 400 units. b. The initial comprehensive assessment completed at start of care, dated 8/19/21, lacked documentation of completion of a drug regimen review including all of the required components: potential adverse effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. c. During a home visit observation on 10/12/2021 at 9:53 AM, the surveyor accompanied Staff D, Registered Nurse (RN), to Patient #2's residence. During the home visit, the surveyor and the nurse reviewed the medications in the patient's home. The nurse and patient both revealed the patient was able to independently set up med box. The surveyor observed the Calcium Carbonate plus Vitamin D3 and noticed the dosage on the bottle was 600 mg of Calcium Carbonate and 800 units of Vitamin D3. The incorrect medication dosage was added to the Plan of Care and the agency medication profile. The clinical record lacked documentation of completion of a drug regimen review. 3. Patient #4 had a start of care date of 6/30/2020. Clinical record review revealed: a. The Plan of Care, dated 4/26/21 to 6/24/21, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment for recertification, dated 4/22/21, included a drug regimen review, but lacked inclusion of evaluation of potential adverse effects/reactions, ineffective drug therapy and drug interactions. The clinical record lacked documentation of a complete drug regimen review. 4. Patient #6 had a start of care date of 2/19/15. Clinical record review revealed: a.The Plans of Care, dated 5/18/21 to 7/16/21, 7/17/21 to 9/14/21, and 9/15/21 to 11/13/21, included orders for home health aide services. b. The updates to the comprehensive assessment for recertification, dated 5/14/21, 7/13/21, and 9/14/21, included a drug regimen review, however failed to include the components of potential adverse effects and drug reactions, ineffective drug therapy, significant drug interactions, and noncompliance with drug therapies. The clinical record lacked documentation of complete drug regimen reviews. 5. Patient #8 had a start of care date of 8/29/18. Clinical record review revealed: a. The Plans of Care dated 4/15/21 to 6/13/21, 6/14/21 to 8/12/21, and 8/13/21 to 10/11/21, included physician’s orders for skilled nursing and home health aide services. b. The updates to the comprehensive assessment, dated 4/17/21, 6/9/21, and 8/12/21 included a drug regimen review, however failed to include the components of potential adverse effects and drug reactions, ineffective drug therapy, significant drug interactions, and noncompliance with drug therapies. The clinical record lacked documentation of complete drug regimen reviews. The surveyors reviewed the above findings for Patients #2, #3, #4, #6, and #8 with agency Administrator. Agency staff provided no further information prior to the end of the survey.

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, agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 3 of 7 sampled patients requiring a recertification assessment (Patients #5, #6 and #8). The agency reported a census of 61 patients at the time of the survey. Failure to complete the updates to the comprehensive assessment at recertification in a timely manner increased the potential that patients might not receive services in a timely manner according to assessed needs. Findings include: " ". Patient #1 had a start of care date of 10/09/2019. Clinical record review revealed the following: a. The Plan of Care, dated 9/28/2021 to 11/26/2021 indicated the certification period ended on 9/27/2021 and was electronically signed on 9/30/2021. b. The Skilled nurse Comprehensive Recertification assessment dated 9/27/2021 was electronically signed on 9/30/2021. The update to the comprehensive assessment at recertification, dated 9/27/2021 was completed 3 days late. Review of the agency policy, titled Patient Reassessment/Recertification/Significant Change in Condition/Post Hospital Assessment, dated 5/2018, clinicians must complete the update to the comprehensive assessment at recertification during the last five days of every 60 day period. 1. Patient #5 had a start of care date of 2/22/21 and transferred from agency services on 8/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 4/23/21 to 6/21/21 and 6/22/21 to 8/20/21, included orders for home health aide services 1 to 2 days per week. b. Interim physician orders, dated 4/19 and 6/21/21, included a physician order for skilled nursing one time every 56 to 60 days. c. The update to the comprehensive assessment completed at the time of recertification, dated 6/21/21, included a signature of completion, dated 6/23/21 (completed 2 days late). On 10/13/21 at 1:27 PM, during an interview, the Clinical Manager revealed she was unaware clinicians had to sign completion of the update to the comprehensive assessment due at the time of recertification by the end of day 60 of the certification period. On 10/13/21 at 2:23 PM, during an interview, the Clinical Manager reported an inability to find any further information. 3. Patient #6 had a start of care date of 2/19/15 and received home health aide services paid for by Medicaid, thereby requiring the collection of OASIS data set. Clinical record review revealed the following: a. The Plan of Care, dated 5/18/21 to 7/16/21, included physician orders for home health aide services. b. The patient's clinical record included an update to the comprehensive assessment at the time of recertification, dated 7/13/2021 (day 56 of the current certification period). The assessment was electronically signed as complete on 7/25/2021, day 9 of the new certification period, making the assessment nine days late. 4. Patient #8 had a start of care date of 8/29/18 and received skilled nursing and home health aide services paid for by Medicare, thereby requiring the collection of OASIS data set. Clinical record review revealed the following: a. The Plan of Care, dated 4/15/21 to 6/13/21, included physician orders for skilled nursing and home health aide services. b. The patient's clinical record included an update to the comprehensive assessment at the time of recertification, dated 4/14/2021 (day 60 of the current certification period). The assessment was electronically signed as complete on 4/16/2021, day 2 of the new certification period, making the assessment two days late. The surveyors reviewed the above findings for Patients #1, #5, #6, and #8 with agency Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed a transfer summary and sent the transfer summary to the receiving facility for 1 of 1 sampled patients (Patient #5) reviewed requiring the completion of a transfer summary. The agency reported a census of 61 patients at the time of the survey. Failure to complete and send a transfer summary to the receiving facility placed agency patients at risk for not ensuring the safe and effective transition of patient care. Findings include: Review of the agency's policy, titled Client Transfer, dated 1/2018, revealed agency staff will notify the physician of the patient's transfer. No later than 48 hours after the transfer, agency staff will provide the receiving agency with the following: documentation of services provided, specific care, psychosocial status, medications, other organizations involved in care and any advanced directives. Patient #5 had a start of care date of 2/22/21 and transferred from agency services on 8/12/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 4/23/21 to 6/21/21 and 6/22/21 to 8/20/21, included orders for home health aide services 1 to 2 days per week. b. Interim physician orders, dated 4/19 and 6/21/21, included a physician order for skilled nursing one time every 56 to 60 days. c. A home health aide visit note, dated 8/12/21, included documentation which identified the home health aide was unable to provide services due to the patient being admitted to the hospital. The clinical record lacked documentation of any further visits by agency staff. The clinical record lacked documentation of a transfer summary, contact with the POC physician regarding the patient's hospitalization or contact with the hospital that admitted the patient. On 10/13/21 at 1:27 PM, during an interview, the Clinical Manager confirmed the clinical record lacked a transfer summary. The Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a doctor of medicine, osteopathy or podiatry or notify the physician of the need to vary from the physician ordered Plan for Care for 2 of 8 sampled patients (Patients #2 and #8). The agency reported a census of 61 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 1. Patient #2 had a start of care date of 8/19/21. Clinical record review revealed: a. The Plan of Care, dated 8/19/2021 to 8/10/17/2021, included physician orders for the skilled nurse to obtain height, weight, and body mass index. b. Skilled nursing visit note, dated 8/26/21, documented the patient needed new batteries for her scale so unable to obtain weight. The visit lacked documentation of the patient’s height and why the height was not obtained. c. Skilled nursing visit notes, dated 8/31/21, 9/16/21, and 10/12/21, documented the patient’s weight and BMI. The visit note lacked documentation of the patient’s height and why the height was not obtained. d. Skilled nursing visit notes, dated 9/2/21, 9/9/21, 9/24/21, 10/1/21, and 10/5/21, lacked documentation of the patient’s height, weight, and BMI and lacked documentation of why the height, weight, and BMI were not obtained. 2. Patient #8 had a start of care date of 8/29/18. Clinical record review revealed: a. The Plans of Care, dated 8/13/21 to 10/11/21, included physician orders for the skilled nurse to obtain vital signs with pulse oximeter and skilled observation and assessment of all systems. b. The skilled nursing visit notes, dated 8/25/21, 9/8/21, 9/22/21, 9/27/21, lacked documentation of vital signs with pulse oximeter and skilled observation and assessment of all systems. The surveyor reviewed the above findings for Patients #2 and #8 with agency Clinical Manager. Agency staff provided no further information prior to the end of the survey. Review of the agency policy, titled Implementing Care and Treatment, dated 7/30/2018, identified agency staff will notify the patient's physician when agency staff can not implemented provision of care/treatment as established on the Plan of Care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and home visit observation, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 2 of 8 sampled patients (Patients #2 and #4). The agency reported a census of 61 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #2 had a start of care date of 8/19/21. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 8/19/21 to 10/17/21, documented the following as equipment and supplies as equipment used to meet the patient's needs: bath chair, bed rail, compression stockings, glasses, grab bars, med box, walker, single cane, reacher, and blood pressure machine. b. During a home visit observation on 10/12/21 beginning at 9:53 AM with Staff D, Registered Nurse (RN), the surveyor observed the patient with her walker. The walker had a tray to carry things and the patient revealed use of the tray for as long as the patient was using the walker. The Plan of Care, dated 8/19/21 to 10/17/21, lacked inclusion of the walker tray as supplies used to meet the patient's needs. c. During the same home visit observation with Staff D, Registered Nurse (RN), the surveyor observed the nurse weighing the patient with the patient’s scale. The Plan of Care, dated 8/19/21 to 10/17/21, lacked inclusion of the scale as equipment used to meet the patient's needs. d. During the same home visit observation with Staff D, Registered Nurse (RN), the surveyor observed the patient wearing an orthotic shoe to the left foot. The patient revealed use of the orthotic shoe since returning home from the nursing home. The Plan of Care, dated 8/19/21 to 10/17/21, lacked inclusion of the orthotic shoe as equipment used to meet the patient's needs. 3. Patient #4 had a start of care date of 6/30/2020. Clinical record review revealed the following: a. The Plan of Care, dated 8/24/21 to 10/22/21, documented the following as equipment and supplies as equipment used to meet the patient's needs: walker, single cane, med box, grab bars, glasses, dentures, lifeline and lift chair. b. Skilled nursing visit notes, dated 10/5/21 and 10/12/21, documented the patient use of poise pads for urinary incontinence. The Plan of Care, dated 8/24/21 to 10/22/21, lacked inclusion of incontinence supplies as equipment used to meet the patient's needs. The surveyors reviewed the above findings for Patients #1, #2 and #4 with agency Clinical Manager. Agency staff provided no further information prior to the end of the survey. Review of the agency policy, titled Plan of Care, dated 7/30/2018, identified the Plan of Care (POC) will include medical supplies and equipment required by the patient. Agency staff will use information gathered during patient assessments in the care planning process and update the POC at least every 60 days, but also with patient condition/need changes, changes in physician orders and changes in goals.

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 clinical record review, agency policy review and agency staff interview, the agency staff failed to provide medications and treatments only as ordered by the physician for 1 of 2 sampled patients (Patients #2) receiving wound care. The agency reported a census of 61 patients at the time of the survey, and a total of 3 patients with wounds. Failure to ensure staff obtain/follow physician orders for wound treatments placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Patient #2 had a start of care date of 8/19/21. Clinical record review and associated interviews revealed the following: a.The Plan of Care, dated 8/19/21 to 10/17/21, documented the diagnoses of cellulitis of left toe and complete traumatic amputation of left great toe.. The Plan of Care ordered skilled nursing services 1-2 times per week. b. The initial comprehensive assessment completed at start of care, dated 8/19/21, documented the presence of a small scab over the amputated toe site, but no drainage present. c. Skilled nursing visit note, dated 9/9/21, documented the tip of right 2nd toe scab intact and amount of tan drainage tain in color on dressing. The nurse cleansed and applied triple antibiotic. The patient’s family has been doing dressing changes every 2-3 days. The clinical record lacked an order for the nurse to cleanse the wound and apply the triple antibiotic ointment. d. During a home visit observation with Staff D, Registered Nurse (RN) on 10/12/21 beginning at 9:53AM, the surveyor observed the RN performing wound care to the patient’s left foot where the patient had the left great and left 2nd digit removed. The nurse revealed to the surveyor that staff were performing “just a dry dressing” as no orders received for dressing changes. e. The patient's clinical record lacked documentation of any communication with the physician to obtain orders for dressing changes to the left foot. Agency staff performed dressing changes without obtaining orders from the physician. The surveyor reviewed the above findings for Patient #2 with agency Clinical Manager. Agency staff provided no further information prior to the end of the survey. Review of the agency policy, titled Plan of Care, dated 7/30/2018, identified the registered nurse (RN) is responsible for coordinating the Plan of Care (POC). Agency staff will utilize information gathered during patient assessments in the care planning process. The POC includes specific procedures/treatments to ensure care provided to the patient meets the specific individualized needs and problems of the patient.

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 clinical record review, agency policy review and staff interview, the agency failed to report changes in patient clinical findings to the physician for 1 of 2 sampled patients (Patient #2) with wounds. The agency reported a census of 61 patients at the time of the survey. Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: Patient #2 had a start of care date of 8/19/21. Clinical record review and associated interviews revealed the following: a. The Plan of Care, dated 8/19/21 to 10/17/21, documented the diagnoses of cellulitis of left toe and complete traumatic amputation of left great toe.. The Plan of Care ordered skilled nursing services 1-2 times per week. b. The initial comprehensive assessment completed at start of care, dated 8/19/21, documented the presence of a small scab over the amputated toe site, but no drainage present. c. Skilled nursing visit note, dated 8/31/21, documented the left amputation site for great toe has dropped the 2 small scabs that had been present and the skin under them was pink and intact. d. Skilled nursing visit note, dated 9/9/21, documented the tip of right 2nd toe scab intact and amount of tan drainage tain in color on dressing. The nurse cleansed and applied triple antibiotic. The patient’s family has been doing dressing changes every 2-3 days. e. Skilled nursing visit note, dated 9/16/21, documented the patient was seen by the podiatrist that morning and will go in next week to have 2nd toe on left foot amputated. The patient refused to allow the nurse to look at the area since it was dressed by the podiatrist and refused an increase in nurse visits for dressing changes as the family can do the dressing changes. f. Skilled nursing visit note, dated 9/24/21, documented patient was tired and had foot surgery, amputation on left 2nd toe yesterday. The patient had a large dressin on foot with ortho shoe in place and discharge orders were to leave dressing in place until sees the podiatrist and the podiatrist will remove it at appointment next week. g. Skilled nursing visit note, dated 10/5/21, documented family had just finished changing dressing to left foot surgery site, but patient did allow RN to look at the area. No drainage present and sutures were intact with no redness or swelling. h. Skilled nursing visit note, dated 10/12/21, documented the patient saw the podiatrist last week and was pleased with progress on amputation site. The incision on foot is dry and scab intact with no signs and symptoms of redness or infection. Blister area on outer aspect of foot is pink purple now and less fluid filled. i. During a home visit observation with Staff D, Registered Nurse (RN) on 10/12/21 beginning at 9:53AM, the surveyor observed the RN performing wound care to the patient’s left foot where the patient had the left great and left 2nd digit removed. The nurse revealed to the surveyor that staff were performing “just a dry dressing” as no orders received for dressing change. j. The patient's clinical record lacked documentation of any communication with the physician to obtain orders for dressing changes to the left foot. The surveyor reviewed the above findings for Patient #2 with agency Clinical Manager. Agency staff provided no further information prior to the end of the survey. Review of the agency policy, titled Implementing Care and Treatment, dated 7/30/2018, identified agency staff will notify the patient's physician when agency staff can not implemented provision of care/treatment as established on the Plan of Care.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and home visit observation the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice for staff observed during a home visit for 2 of 3 patients (Patients #1 and #2). The agency reported a current census of 61 patients at the time of the survey. Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings Include: According to agency policy, titled Hand Hygiene, dated 12/16/2015 hand hygiene will be performed before each patient encounter, before applying gloves, after coming in contact with patient’s intact skin, i.e., taking a patient’s blood pressure, pulse, lifting/moving the patient, after contact with medical equipment/supplies in patient areas, after removing gloves or facemasks and after working on a contaminated body site and then moving to a clean body site on the same patient. According to agency policy, titled Nursing Bag Technique, dated 05/2018 when the visit is completed, supplies/equipment shall be contained/disposed of as necessary. Reusable equipment will be cleaned using alcohol, antiseptic spray, and or soap and water as appropriate. Hands will be cleansed prior to returning clean equipment and supplies to the bag. Paper towels/newspapers used as a protective barrier for bag placement in the patient’s home will be disposed of properly. 1. Patient #1 had a start of care date of 10/09/2019. Observation during a home visit on 10/11/21 at 1:30 PM with Staff E, Registered Nurse (RN), revealed the following: a. Staff E sanitized her hands with alcohol based hand rub, applied gloves and typed on her laptop. b. Staff E sanitized her gloved hands with alcohol based hand rub entered the nursing bag and removed a pulse oximeter and thermometer placed the pulse oximeter on the patient's finger, removed the thermometer from its box and placed a shield on the thermometer and took the patient’s temperature. Removed the pulse oximeter and placed it on the table next to the patient with the thermometer. Typed on the laptop. Then moved the pulse oximeter and thermometer to the the laptop keyboard. She wipes the pulse oximeter and thermometer with sanitizing wipes and places them back in nursing bag. c. Staff E entered the nursing bag removed a blood pressure cuff and placed the cuff on the patient, entered the nursing bag and removed a stethoscope and placed this around her neck, checked the patient's blood pressure, removed the blood pressure cuff and cleaned the cuff with a sanitizing wipe and returned the cuff to the nursing bag. d. Staff E listened to the patient's heart and lungs, wipes the stethoscope with sanitizing wipes and places in nursing bag. Enters nursing bag and takes PT/INR (Prothrombin Time and International Normalized Ratio) machine out, removes it from the cloth case and places it on napkins on table beside chair. Performs PT/INR test, finger poked with lancet from case and blood sample obtained, drop placed on strip inserted in meter. e. Staff E completes test and wipes PT/INR machine with sanitizing wipes and replaces machine and supplies to the cloth case. Types on the laptop. f. Staff E begins assessment of patient’s right lower extremity (RLE). The nurse removes patient’s shoe and sock. She gathers bath basin and wash cloth from bathroom and cleans patient’s RLE with warm water. Replaces sock and shoe. g. Staff E. assists patient to stand on scale and obtains patient’s weight. She uses cell phone to call physicians office and sanitizes her gloved hands with alcohol based hand rub. h. Staff E. measures two visible scabbed areas and writes on measuring tape with pen. She removes gloves throws them in trash and sanitizes her hands with alcohol based hand rub. Staff E. failed to cleanse her hands after performing assessment of patient’s pulse oximetry, temperature, blood pressure and listening to the patient’s heart and lungs. Staff E. failed to cleanse her hands before and after working on a contaminated body site. Staff E. failed to cleanse her hands before getting into the nursing bag and prior to returning cleaned equipment to the nursing bag. Staff E. failed to remove gloves prior to sanitizing with alcohol based hand rub. 2. Patient #2 had a start of care date of 8/19/21. Clinical record review revealed the following: The Plan of Care (POC), dated 8/19/21 to 10/17/21, included physician orders for skilled nursing services 1-2 times per week. During a home visit observation on 10/12/21 beginning at 9:53 AM, the surveyor met with Staff D, Registered Nurse (RN), with the patient in the patient's home. The nurse wore a surgical mask and faceshield into the patient’s home. The nurse cleaned off the patient’s kitchen counter with a wipe and placed the nursing bag on the counter. The nurse removed a smaller bag with vital signs equipment from the nursing bag and applied gloves to bilateral hands. Thermometer scanned to forehead and reading obtained. Next pulse oximeter applied to left index finger. Stethoscope used to listen to heart, lungs, and bowel sounds. The nurse used gray Sanicloth wipes to clean all equipment and immediately returned equipment to the bag. Failure to allow equipment to dry per manufacturer’s instructions for the recommended 3 minutes prior to returning to the bag may potentially not allow the equipment to be cleaned and contaminate the vital signs equipment bag. The nurse then obtained patient’s weight on scale. The nurse then removed the patient’s orthotic shoe to left foot, sock, and dressing. The nurse proceeded to clean the patient’s surgical site with vashe wound solution and gauze, using the same gloves used for patient’s assessment. 2x2 gauze then applied to 2nd digit removal site and taped in place with paper tape. The nurse proceeded to reapply the patient’s sock and orthotic shoe. All dirty supplies were placed in gloves and gloves were removed and discarded. Failure to follow basic hand hygiene of hand sanitizing at beginning of visit, prior to wound care, and at end of the visit and using new gloves for wound care, placed the patient at risk for infection. The surveyors reviewed the above findings for Patients #1 and #2 with the agency Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 6 of 7 sampled patients receiving home health aide services (Patients #2, #3, #4, #6 and #8). The agency reported 43 out of 61 patients received home health aide services at the time of the survey. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: " ". Patient #3 had a start of care date of 6/8/21. Clinical record review revealed: a. The plans of care, dated 10/6//21 to 12/4/21 and 8/7/21 to 10/5/21, included the tasks shower every visit, shampoo every visit, partial sponge bath when requested, dress upper body when requested, dress lower body when requested, deodorant apply per request, lotion to areas directed by patient, comb/brush hair per request, tidy patient care area each visit, for the aide to complete. b. The home health aide visit notes, dated 8/10/21, 8/17, 8/20, 8/24, 8/27, 8/31, 9/3, 9/7, 9/10, 9/14, 9/17, 9/21, 9/24, 9/28, 10/1, 10/5, 10/8/21, lacked documentation the aide completed the task shampoo every visit and lacked documentation of a reason why the task was not completed. The agency failed to ensure the home health aide provided care according to the aide plan of care. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. 3. Patient #2 had a start of care date of 8/19/21. Clinical record review revealed the following: a. The Plan of Care, dated 8/19/21 to 10/17/21, included physician orders for home health aide visits 1-2 times weekly to assist with dressing upper body each visit and applying lotion to areas directed by patient. b. The home health aide visit note, dated 9/7/2021, lacked documentation of the aide performing the task of applying lotion as directed by patient and did not identify why the task was not performed. c. The home health aide visit notes, dated 9/28/2021 and 10/1/2021, lacked documentation of the aide performing the tasks of assist with dressing upper body each visit and applying lotion as directed by patient and did not identify why the tasks were not performed. 4. Patient #4 had a start of care date of 6/30/2020. Clinical record review revealed the following: a. The Plans of Care, dated 6/25/21 to 8/23/21 and 8/24/21 to 10/22/21, included physician orders for home health aide visits 1-2 times weekly to maintain standard precautions/infection control every visit, assist with dressing putting on shoes and socks per patient request, assist with upper body dressing per patient request, and assist with shampooing hair eavh visit unless the patient refuses. b. The home health aide visit notes, dated 8/10/2021 and 8/20/21, lacked documentation of the aide performing the task of shampooing hair and identified the task was not ordered for the visit. c. The home health aide visit note, dated 10/5/2021, lacked documentation of the aide performing the tasks of assisting the patient with dressing putting on shoes and socks per patient request, assist with upper body dressing per patient request, assist with transfers in and out of the shower, and shampooing patient's hair each visit unless the patient refused and did not identify why the tasks were not performed. 5. Patient #6 had a start of care date of 2/19/15. Clinical record review revealed the following: a. The Plans of Care, dated 7/17/21 to 9/14/21 and 9/15/21 to 11/13/21, included physician orders for home health aide visits 1-2 times weekly to apply powder to abdominal skin folds and groin as requested, apply calmoseptine to buttocks per request for redness, apply lotion to torso and extremities per patient request, apply deodorant bilaterally after shower per patient request, apply skin barrier/protectant to perineum per patient request, massage patient per patient request, and provide nail care per patient request. b. The home health aide visit note, dated 8/10/2021, lacked documentation of the aide performing the tasks of apply calmoseptine to buttocks per request for redness, assist with putting on shoes as needed, apply lotion to torso and extremities per patient request, apply deodorant bilaterally after shower per patient request, apply skin barrier/protectant to perineum per patient request and provide nail care per patient request and lacked documentation of why the tasks were not completed. c. The home health aide visit notes, dated 8/13/21 and 9/24/2021, lacked documentation of the aide performing the tasks of apply calmoseptine to buttocks per request for redness, apply lotion to torso and extremities per patient request, apply deodorant bilaterally after shower per patient request, apply skin barrier/protectant to perineum per patient request, massage patient per patient request, and provide nail care per patient request and lacked documentation of why the tasks were not completed. d. The home health aide visit notes, dated 8/17/21 and 9/28/2021, lacked documentation of the aide performing the tasks of apply calmoseptine to buttocks per request for redness and apply lotion to torso and extremities per patient request and lacked documentation of why the tasks were not completed. e. The home health aide visit note, dated 8/13/2021, lacked documentation of the aide performing the tasks of assist with putting on shoes as needed, apply lotion to torso and extremities per patient request and lacked documentation of why the tasks were not completed. f. The home health aide visit notes, dated 8/27, 9/3, 9/7, and 9/10/2021, lacked documentation of the aide performing the tasks of apply lotion to torso and extremities per patient request, apply deodorant bilaterally after shower per patient request, apply skin barrier/protectant to perineum per patient request, massage patient per patient request and provide nail care per patient request and lacked documentation of why the tasks were not completed. g. The home health aide visit notes, dated 8/31/21 and 9/21/2021, lacked documentation of the aide performing the tasks of apply lotion to torso and extremities per patient request, apply deodorant bilaterally after shower per patient request, massage patient per patient request and provide nail care per patient request and lacked documentation of why the tasks were not completed. h. The home health aide visit notes, dated 9/14/21 and 9/16/21, lacked documentation of the aide performing the tasks of apply powder to abdominal skin folds and groin as requested, apply lotion to torso and extremities per patient request, apply deodorant bilaterally after shower per patient request, apply skin barrier/protectant to perineum per patient request, massage patient per patient request and provide nail care per patient request and lacked documentation of why the tasks were not completed. i. The home health aide visit notes, dated 10/1/21 and 10/5/21, lacked documentation of the aide performing the task of provide nail care per patient request and lacked documentation of why the tasks were not completed. j. The home health aide visit note, dated 10/8/21, lacked documentation of the aide performing the tasks of massage patient per patient request and provide nail care per patient request and lacked documentation of why the tasks were not completed. 6. Patient #8 had a start of care date of 8/29/18. Clinical record review revealed the following: a. The Plan of Care, dated 8/13/21 to 10/11/21, included physician orders for home health aide visits 2-3 times weekly to assist with task of suprapubic catheter care including assisting patient to wash around the cath site with soap and water, pat dry, tape 2 4x4s to cover the site, and report any redness or increased drainage from the site. b. The home health aide visit notes, dated 9/29/2021 and 10/6/21, lacked documentation of the aide performing task of suprapubic catheter care including assisting patient to wash around the cath site with soap and water, pat dry, tape 2 4x4s to cover the site, and report any redness or increased drainage from the site and did not identify why the task was not performed. The surveyors reviewed the above findings for Patients #2, #3, #4, #6, #7, and #8 with agency Clinical Manager. Agency staff provided no additional information prior to the end of the survey. Review of the agency policy, titled Home Health Aide Supervision, dated 7/2021, identified the supervising clinician will supervise the home health aide to assure the home health aide is providing services according to the care plan. 1. Patient #7 had a start of care date of 2/1/21 and discharged from agency services on 9/27/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/31/21 to 9/28/21, included physician orders for home health aide services 1 to 2 times per week and skilled nursing services one time every 56-60 days. b. The home health aide care plan, dated 2/1/21, included registered nurse (RN) instructions to the home health aide to complete the tasks of shampoo the patient's hair, comb the patient's hair and shave the patient per the patient's request. c. The home health aide visit notes, dated 8/2, 8/5, 8/19, 8/23, and 9/20/21, lacked documentation on whether or not the home health aide offered to do the tasks of combing the patient's hair and shaving the patient or if the patient refused. d. The home health aide visit notes, dated 8/9, 8/26, 8/30 and 9/2/21, lacked documentation on whether or not the home health aide offered to do the tasks of shampooing the patient's hair, combing the patient's hair and shaving the patient or if the patient refused. e. The home health aide visit note, dated 8/16/21, lacked documentation on whether or not the home health aide offered to do the task of shaving the patient or if the patient refused. On 10/12/21 at 3:30 PM, during an interview, the Clinical Manager reported she planned to provide education to staff on documenting tasks and the reason why if they do not complete an assigned task in the home health aide visit notes.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing each home health aide present and providing direct patient care for 1 of 3 sampled patients who received hands on personal care services with no skilled service provision. (Patient #6). The agency reported a current census of 61 patients, including 24 patients who received personal care assistance by a home health aide without any skilled service provision. Failure to supervise home health aide services, at least every 60 days while the aides provided direct patient care, increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: Patient #6 had a start of care date of 2/19/15. Clinical record review revealed the following: a. The Plans of Care, dated 5/18/21 to 7/16/21 and 7/17/2021 to 9/14/2021, included physician orders for home health aide services without the provision of skilled services. b. The aide supervisory note, dated 7/13/21, documented indirect supervision of the home health aide during a visit with the patient when the home health aide was not present. The clinical record lacked documentation of any other supervisory visits associated with the 60 day period prior to the 7/17/2021 to 9/14/2021 certification period. c. The aide supervisory note, dated 9/14/21, documented indirect supervision of the home health aide during a visit with the patient when the home health aide was not present. The clinical record lacked documentation of any other supervisory visits associated with the 60 day period prior to the 9/15/2021 to 11/13/2021 certification period. At the time of the surveyor's clinical record review on 10/13/2021, 152 days after the last supervisory visit, the record lacked any further documentation of aide supervision. On 10/13/21 at 1:10 PM, the surveyor reviewed the above stated findings with the agency Clinical Manager. The Clinical Manager revealed no direct aide supervision occurred because a licensed practical nurse was in the patient's home providing aide services so there was no aide present to directly supervise. The agency provided no additional information prior to the end of the survey. Review of the agency policy, titled Home Health Aide Supervision, dated 7/2021, identified the supervising clinician must make a supervisory visit to the patient's residence at least once every 60 days and observe the home health aide providing direct patient care.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure authentication of entries made in each patient's clinical record included the employee's title and failed to complete timely documentation as directed by agency policy for 4 of 8 sampled patients (Patients #2, #4, #6 and #8). The agency reported a census of 61 patients at the time of the survey. Failure to maintain timely, accurate and appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: 1. Patient #2 had a start of care date of 8/19/2021. Clinical record review revealed the following: a. The Plan of Care, dated 8/19/2021 to 10/17/2021, included orders for home care aide services. b. The home health aide visit note, dated 8/24/2021, was electronically signed with the home care aide title and time of signature however, identified the date completed as 8/29/21, 3 days late according to agency expectation. c. The home health aide visit note, dated 8/31/2021, was electronically signed with the home care aide title and time of signature however, identified the date completed as 9/6/21, 4 days late according to agency expectation. d. The skilled nursing visit note, dated 10/1/2021, was electronically signed with the home care aide title and time of signature however, identified the date completed as 10/5/21, 2 days late according to agency expectation.. 2. Patient #4 had a start of care date of 6/30/2020. Clinical record review revealed the following: a. The Plan of Care, dated 8/24/2021 to 10/22/2021, included orders for home care aide services. b. The home health aide visit notes, dated 9/3, 9/7, 9/10, 9/14, 9/21, 9/23, 9/28/21, and 10/7/21 were electronically signed with the home care aide's name, date and time of signature however, lacked the title of the discipline completing the note. c. The home health aide visit notes, dated 9/27/2021 and 10/5/21, were not locked and completed by the home care aide, exceeded agency expectation of 48 hours for date of completion.. 3. Patient #6 had a start of care date of 2/19/15. Clinical record review revealed the following: a. The Plan of Care, dated 9/15/2021 to 11/13/2021, included orders for home care aide services. b. The home health aide visit notes, dated 10/1, 10/5, and 10/8/2021, were electronically signed with the home care aide's electronic signature, date and time of signature however, lacked identification of the title of the discipline completing the note. 4. Patient #8 had a start of care date of 8/29/18. Clinical record review revealed the following: a. The Plan of Care, dated 8/13/2021 to 10/11/2021, included orders for home care aide services. b. The home health aide visit note, dated 8/16/21, was electronically signed with the home care aide title and time of signature however, identified the date completed as 8/30/21, 12 days late according to agency expectation. c. The home health aide visit note, dated 8/20/21, was electronically signed with the home care aide title and time of signature however, identified the date completed as 8/30/21, 11 days late according to agency expectation. d. The home health aide visit note, dated 10/8/21, was electronically signed with the home care aide title and time of signature however, identified the date completed as 10/11/21, 1 day late according to agency expectation. The surveyor reviewed the above findings for Patients #2, #4, #6, and #8, with agency Clinical Manager. Agency staff provided no additional information prior to the end of the survey. Review of the agency policy, titled Patient Assessment Guidelines, dated 5/2018, identified assessments must be completed within 48 hours. On 10/13/21 at 2:40 PM, during an interview, the Clinical Manager explained the policy related to clinical records and time frame completions, titled Patient Assessment Guidelines, meant not only assessments, but all visit note documentation. She reported all disciplines must complete documentation of visit notes within 48 hours.