Every finding on record at Hannibal Regional Hospital

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 02/21/2024. During the survey, it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 02/21/2024. The provider had 100 current patients.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to update and revise the patient’s comprehensive assessment when the patient had a significant decline in condition in, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Significant Change In Condition (SCIC),” last reviewed 07/2022, showed in part: - Examples of SCICs include, but are not limited to, the addition of another discipline on the case due to a decline in the patient's condition and an unanticipated significant functional improvement in a patient; - Staff will report a significant change in condition to attending physician or approved practitioner; and - Staff will document changes in the patient's condition or status on the day the change in condition is observed in the form a follow up or resumption of care. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2024 with a primary diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning) with anxiety (intense, excessive, and persistent worry and fear about everyday situations); and - The patient resided at home with spouse. Review of the PT (Physical Therapy) communication note, dated 02/07/2024, showed in part: - The patient complained of abdominal discomfort as well as having a lump in his/her genital area; and - Informed the RN (registered nurse) CM (case manager). Review of the COTA (Certified Occupational Therapy Assistant) communication note, dated 02/13/2024, showed in part: - The patient’s spouse reported that the patient had surgery that day on his/her toe due to an infection from an ingrown toenail and that there was further issues with the patient's UTI (urinary tract infection) that they were trying to get more doctors in on to assess; - Call placed to the SN (skilled nurse) in regard to patient surgery and further UTI treatment; and - Message sent to the PT, the PTA (Physical Therapy Assistant), and the OT (Occupational Therapy). Review of the PT communication note, dated 02/14/2024, showed in part: - A message was received from the receptionist stating that the patient's spouse called and cancelled any further visits that week; - The patient's spouse spoke with the COTA and said the patient had an ingrown toenail removed and was also concerned about a UTI; - The patient also refused PT yesterday; and - The physician was informed per E fax (electronic fax). Review of the RN (registered nurse) CM (case manager) communication note, dated 02/16/2024, showed that the RN CM had received report from all clinicians on visits that week. Review of the RN CM communication note, dated 02/20/2024, showed in part: - SCIC completed that day (This was after the SA (State Agency; survey team) had entered the home health provider and 13 days after the initial change in condition was reported); - The patient's spouse reported that he/she had concerns the patient had a return of a UTI and complained of abdominal pain that came and went; - During the SCIC visit the SN palpated the patient's abdomen and notable left lower rebound pain was documented; - The SN asked permission to assess the patient’s complaint of a genital problem of a “growth,” and it appeared the patient's bladder was prolapsing through the peri area with the initial visual assessment; - The SN called and received orders to obtain a UA (urinalysis; a test to analyze urine content) and do could do a clean catch or straight cath (catheter; an intermittent, soft, thin tube used to pass urine from the body); - The bulging area from the genital area was noted to be decreased after the catheter was removed; -The SN informed the patient and spouse that the skilled nurse would like to monitor the bulging area closely and would follow up with the doctor the next morning as business hours had concluded for further instructions; - Skilled nursing would see the patient again Friday and twice weekly for the remainder of the certification period and collaborate with the physicians to provide the patient and caregiver optimal tools for success for optimal health goals and safety; - A UA was obtained to check for the presence of a UTI via straight catheter; - SN visits were added; and - SN would continue to monitor. During an interview on 02/21/2024 at 3:40 PM, the clinical manager stated that; - He/she would have expected the SCIC to be completed sooner; and - He/she would expect the nurse to do an assessment within 24 hours of the reported change in the patient’s condition.

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 policy review, record review, and interview, the home health provider failed to ensure treatments were provided as ordered by the physician, when the staff educated the patient not to lift over 10 pounds and the physician ordered no lifting, in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Treatment,” last reviewed 02/2022, showed in part: - The plan of care shall include the patient’s functional limitations and permitted activities; - Consultation with patients physician or allowed practitioner and modifications to the plan of care shall be documented; and - Care will be delivered according to the most recent order. RECORD/PATIENT #4: Review of the referral orders, showed in part: - The patient was to discharge home with home health on 02/17/2024; - No lifting until 03/19/2024; and - No driving until 03/19/2024. Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/18/2024 for surgical aftercare following surgery on the circulatory system; and - The patient resided at home with significant other. Review of the multidisciplinary care plan, showed in part: - An intervention to teach sternal precautions from the cardiology binder in the home; - No driving, lifting, or pulling greater than 10 pounds (The referral order showed no lifting until 03/19/2024 and did not include no lifting greater than 10 pounds); - An intervention to teach and encourage the use of pillow on the chest when transitioning positions sitting to standing and vice versa, again refer to cardiology binder within the home (The cardiology binder is a preprinted booklet that was provided to the patient to take home after surgery and did not include patient-specific physician orders); and - The multidisciplinary care plan failed to include the most recent order of no lifting until 03/19/2024. During an interview on 02/21/2024 at 1:45 PM, the clinical manager stated that; - There should have been more specific interventions on the plan of care than just stating to refer to the cardiology binder; - The physician should have been notified for clarification when the referral orders showed no lifting and the binder that was sent home with the patient showed no lifting over 10 pounds; and - He/she would have expected the clinicians to follow the most current physician orders.

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 policy review, record review, and interview, the home health provider failed to promptly alert the physician when the patient had a fall, in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan for Skilled Nursing Care,” last reviewed 09/2022, showed in part: - Prepare clinical and progress notes, and inform the physician and other personnel of changes in the patient's condition and needs, or deviations from the plan of care at least every 60 days; and - Maintain a clinical record for each patient. Review of the provider’s policy titled, “Patient Change in Condition,” last reviewed 02/2022, showed in part: - Clinicians will promptly alert the relevant physician or practitioner 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; and - Clinicians will report changes in condition to attending physician or approved practitioner and collaborate with nurse case manager in any other disciplines involved in the patients care. RECORD/PATIENT #3: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/18/2024 with primary diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting the right side; and - The patient resided at home with spouse. Review of the SN (skilled nurse) visit note, on 01/19/2024, showed in part: - The patient reported a fall without injury; - The patient rated pain 4 out of 10 (0 being no pain and 10 being the worst pain) to the right shoulder from the fall; - The RN (Registered Nurse) CM (Case Manager) was notified of the assessment findings; and - The clinical record failed to show that the physician was notified of the fall. During an interview on 02/21/2024 at 3:50 PM, the clinical director (under the administrator) stated that: - There was no record of the physician being notified of the fall; and - He/she would have expected the physician to be notified and the clinicians to have documented that the physician was notified.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure a policy for emergency staffing strategies was developed for the agency's Emergency Preparedness (EP) plan. This deficient practice has the potential to affect all patients served by the agency. Findings included: The agency did not have a policy to address emergency staffing strategies or the use of volunteers during an emergency, including the process and role for integration of state and federally designated health care professionals to assist with needs during an emergency. During an interview on 08/18/2021 at 10:19 AM, the intake coordinator and registered nurse (RN) stated that the home health agency did not have a policy related to emergency staffing during an emergency in the home health EP plan.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff were provided annual Emergency Preparedness training in five (Employee #1, #2, #3, #4, and #5) of five employee files reviewed. This deficient practice has the potential to affect all patients and staff served by the agency. Findings included: Review of the agency's policies titled, "Staff Development," revised May, 2018 and "Competency Assessment Validation Plan for Home Health," revised February, 2021, failed to include new or current staff training for emergency preparedness (EP) upon hire/during orientation and every two years. Employee #1 (E1): - Date of hire: 12/14/2015; - Position: Registered nurse (RN)/supervisory nurse (SN); and - No evidence of EP training on orientation and every two years. Employee #2 (E2): - Date of hire: 11/09/2020; - Position: Licensed practical nurse (LPN); and - No evidence of EP training on orientation and every two years. Employee #3 (E3): - Date of hire: 03/22/2021; - Position: Certified nurse aide (CNA); and - No evidence of EP training on orientation and every two years. Employee #4 (E4): - Date of hire: 02/27/2017; - Position: Physical therapy assistant (PTA); - No evidence of EP training on orientation and every two years. Employee #5 (E5): - Date of hire: 06/08/2015; - Position: Vice president of nursing; and - No evidence of EP training on orientation and every two years. During an interview on 08/18/2021 at 10:19 AM, the intake coordinator and RN stated that EP training is done through the hospital and is not geared toward home health procedures but they are working on it.

An extended survey for Medicare certification for Hannibal Regional Hospital Home Health Agency was completed on 08/23/2021. The parent office had 98 current patients and the branch office had 9 current patients for a total of 107 current patients. One condition-level deficiency was identified at an immediate jeopardy (IJ) level as follows: - 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. An immediate jeopardy (IJ) level citation related to the likelihood of serious harm for one current patient (Patient #2) and potential for future harm to all other patients was identified during the survey. The findings were confirmed as immediate jeopardy by the Centers for Medicare and Medicaid Services (CMS) Regional Office (RO) on 08/18/2021. On 08/18/2021 at 12:50 PM, the supervisory nurse was informed verbally and in writing, via the IJ Template, of the findings identified at an immediate jeopardy level. A formal written removal plan was submitted by the agency prior to the survey exit. This removal plan was reviewed by the state agency and CMS RO and it was determined, at the time of the survey exit on 08/23/2021, that a satisfactory removal plan had been initiated related to the immediate jeopardy findings. The condition-level deficiency identified above remains as cited. One additional condition-level deficiency was identified during this survey: - 484.105 Condition of Participation: Organization and Administration of Services. A home health agency that is found out of compliance with specific Conditions of Participation evaluated as part of an extended survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) - see Tag G788. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and two standard level deficiencies were identified related to the Focused Infection Control Survey. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey. Two (2) standard level deficiencies were identified.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on the agency current patient rights information, home visit observation, and interview, the agency failed to provide the patient and representative (if any) correct contact information for the current home health agency administrator, to receive complaints in, but not limited two (Record/Patient #1 and #2) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated Patient's Bill of Rights/Responsibilities left in the admission folder in the patient's home showed: - Listed the name and contact information of a director/administrator who no longer was employed by the agency. RECORD/PATIENT #1: During a home visit observation on 08/16/2021 1:15 PM, review of the admission packet left in the home failed to show the current administrator's/director's name and contact information to receive complaints. A previous director/administrator who the agency no longer employed was listed in the admission packet Patient's Bill of Rights/Responsibilities. RECORD/PATIENT #2: During a home visit observation on 08/16/2021 T 2:45 PM, review of the admission packet left in the home, failed to show the current administrator's/director's name and contact information to receive complaints. A previous director/administrator who the agency no longer employed was listed in the admission packet Patient's Bill of Rights/Responsibilities. The record review findings were reviewed with the office manager on 08/17/2021. He/she acknowledged the findings and no additional information was provided.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information included in the home admission folders, and interview, the patient rights information failed to include that patients have the right to participate in, be informed about, and consent or refuse care in advance to and during treatment, where appropriate, with respect to: * vii: Any factors that could impact treatment effectiveness. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's patient rights information in the admission folders did not include the patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to- * vii: Any factors that could impact treatment effectiveness. During an interview on 08/17/2021 at 3:30 PM, the findings were reviewed with the supervisory nurse and he/she acknowledged the findings and provided no additional information.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on the agency's patient rights information in the patient admission packets, and interview, the agency failed to update the written notice of patient rights to include that the patient has the right to be advised of the name, address, and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's patient rights information in the admission packet given to the patients upon admission did not include the complete name and address of the QIO: Livanta LLC, BFCC-QIO Program, 10820 Guilford Road, Suite 202, Annapolis Junction, MD, 20701-1105. The patient rights information was reviewed with the supervisory nurse on 08/17/20221 at 3:30 PM and he/she acknowledged the findings and provided no additional information.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on review of the agency's patient rights information, and interview, the agency failed to include the patient has the right to receive the patient rights information in plain language and in a manner that is accessible and timely. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the admission packet for all patients admitted to service of the agency failed to include the patient has the right to information that is in plain language and in a manner that is accessible and timely. The patient rights information was reviewed with the supervisory nurse on 08/17/20221 at 3:30 PM and he/she acknowledged the findings and no further information was provided.

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 policy review, record review, home visit observation, and interviews, the agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment and that the medication profile was updated with medication changes in, two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency's policy revised on 02/2021 titled, "Medication Management" showed, in part, the following: - On admission, complete medication information will be entered into the EMR (electronic medical record); - If the home medication list and bottles do not match the orders, the skilled nurse will reconcile the home medication orders by calling the physician for clarification and/or by faxing the list to the physician for clarification; and - At each visit the skilled nurse will reconcile any/all new or changed medications and update the medication list. RECORD/PATIENT #2: Review of the plan of care (POC) dated 07/23/2021 through 09/20/2021, showed, in part: - The patient was admitted to home health services on 07/23/2021; and - Diagnoses included: Encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the digestive system (patient had a blockage that required surgery), malignant neoplasm of unspecified ovary (ovary cancer), secondary neoplasm of liver and intrahepatic bile duct (cancer), anemia in neoplastic disease (condition when the body stops producing enough blood cells), dehydration, sepsis (bacterial infection in the blood), diverticulitis of large intestine without perforation or abscess without bleeding (inflammation in the intestine), hypertension (high blood pressure), fibromyalgia (chronic medical condition that affects the muscles and soft tissue causing widespread pain), obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), insomnia (difficulty sleeping), hypokalemia (low potassium levels), hypothyroidism (slow working thyroid), gastro-esophageal reflux disease without esophagitis (indigestion), and constipation (difficulty having bowel movements). Review of the discharge to home medication list from the hospital on 07/22/2021 showed: - Carboplatin (chemotherapy medication for cancer of the ovaries) 508 mg (milligrams) intravenous (into a vein) every 28 days; - Doxil (chemotherapy medication for cancer) 59 mg intravenous every 28 days; and - Neulasta (medication that helps the body make white blood cells after receiving cancer medications) 6mg subcutaneous (under the skin) injection every 28 days. Review of the clinical record failed to show: - Chemotherapy injection medications on the medication profile; and - Clarification from the physician if patient is to continue receiving chemotherapy medications. During an interview on 08/17/2021 at 10:00 AM, the nursing supervisor and registered nurse (RN) A stated: - Medications on the discharge medication list should be clarified with the physician if discrepancies arise; and - No further documentation was provided for the medication discrepancies. RECORD/PATIENT #3: Review of the current Medication Profile printed on 08/16/2021 showed: - Flagyl (an anti-fungal medication) 500 mg, one tablet TID (three times per day) for seven days, start 08/04/2021, end 08/10/2021. Status: Active; - Simethicone (used to relieve painful pressure caused by excess gas in the stomach and intestines) 80 mg, chew 1/2 tablet QID (four times per day) after meals and at bedtime for seven days; no end date, no status documented; and - Ibuprofen (over the counter pain reliever) 200 mg tablets, four tablets every four hours for pain between doses of OxyContin (a narcotic pain reliever) if pain not relieved was not listed on the Medication Profile. During a home visit observation on 08/17/2021 at 10:30 AM, Patient #3 stated that: - He/she did not take Flagyl or Simethicone anymore and stopped the medications a while ago; and - He/she took Ibuprofen, four tablets every four hours for pain, between doses of OxyContin if pain not relieved. During an interview on 08/17/2021 at 11:00 AM, the supervisory nurse stated staff reconcile medications weekly and did not give a reason why the medication profile was not updated.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to: - Promptly alert the relevant physician(s) to any changes in the patient's condition (590); - Coordinate care delivery to meet the patient's needs, and involve the patient, and caregiver, as appropriate in the coordination of care activities (G608); - Ensure that each patient and his or her caregiver where applicable, receive ongoing education and training provided by the HHA (home health agency), as appropriate, regarding care and services identified in the plan of care (G610); - Provide a visit schedule, including frequency of visits to the patient (G614); and - Provide the name and contact information for the clinical manager to the patient (G622). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

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 policy review, record review, observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #2) of five records reviewed. The findings in record #2 and the observations on the home visit resulted in an immediate jeopardy finding. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Treatment," revised February, 2021 showed, in part: - Policy: The patient's plan of care (POC) is developed in consultation with physician, clinical staff, patient, and family or significant other, and is documented on the CMS 485; - The written plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals; - The physician and department staff review the plan of care as often as the severity of the patient's condition requires, but at least once every 60 days; - Department clinical staff alert the physician to any changes that suggest a need to modify the plan of care including visit frequency; and - Care will be delivered according to the most recent order. RECORD/PATIENT #2: Review of the POC dated 07/23/2021 through 09/20/2021, showed, in part: - The patient was admitted to home health services on 07/23/2021; and - Diagnoses included: Encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the digestive system (patient had a blockage that required surgery), malignant neoplasm of unspecified ovary (ovary cancer), secondary neoplasm of liver and intrahepatic bile duct (cancer), anemia in neoplastic disease (condition when the body stops producing enough blood cells), dehydration, sepsis (bacterial infection in the blood), diverticulitis of large intestine without perforation or abscess without bleeding (inflammation in the intestine), hypertension (high blood pressure), fibromyalgia (chronic medical condition that affects the muscles and soft tissue causing widespread pain), obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), insomnia (difficulty sleeping), hypokalemia (low potassium levels), hypothyroidism (slow working thyroid), gastro-esophageal reflux disease without esophagitis (indigestion), and constipation (difficulty having bowel movements). Review of a physical therapy visit on 07/30/2021 at 9:40 AM showed: - The patient had an elevated heart rate of 104 beats per minute (above 100 beats per minutes is out of range); - The patient reported feeling as though she/he is always falling or pulling to the right side and is concerned he/she may have had a stroke; - The patient had a fall that resulted in a head laceration after hitting his/her head on a chair; - Physician was notified about the fall; and - The agency failed to notify the physician of the elevated heart rate, right sided weakness, and patient's concern for having a stroke. Review of a skilled nursing note dated 07/30/2021 at 10:46 AM showed: - Primary care physician was contacted regarding patient having a fall with laceration to right scalp; - Patient was seen for follow up by physician on 07/29/2021 with labs being obtained during follow up visit; - Patient with hemoglobin of 8.5 and diagnosed with hypokalemia, hypomagnesium, hypocalcemia, and thyroid levels dropped despite levothyroxine dosage; and - Orders obtained to recheck labs of CBC (complete blood count) and magnesium on 08/03/2021 and obtain a BMP (basic metabolic panel) on 08/06/2021. Review of a skilled nursing note dated 08/03/2021 at 9:50 AM showed: - Blood work was drawn for CBC (complete blood count) and magnesium levels; - Bruising to arms noted without any other detailed documentation as to how the bruising occurred or when bruising happened; - In the physician contacted section of the skilled nurse visit note, "No one contacted as a result of this visit" was noted; - No other documentation was provided for communication with the physician regarding the hemoglobin level that had decreased to 7.7 from the previous level of 8.5 that was obtained during the follow up visit with physician on 07/29/2021 (5 days earlier) (normal hemoglobin level range is 10.4 to 15.9); and - No other signs or symptoms noted. Review of the occupational therapy (OT) note on 08/06/2021 at 8:30 AM showed: - The patient had an elevated blood pressure of 160/90; - No documentation of a head to toe assessment or assessment of signs or symptoms; and - No documentation that the agency notified the physician of the elevated blood pressure. Review of a skilled nursing note dated 08/06/2021 at 9:20 AM showed: - The patient had a blood pressure of 160/90 (parameters for the top number of 95 to 140 and the bottom number of 60 to 90); - Heart rate (number of times the heart beats in a minute) of 115 beats per minute (parameters of 60 to 100); - Labs were obtained for a basic metabolic panel; and - In the physician contacted section of the skilled nurse visit note, "No one contacted as a result of this visit" was noted. The agency failed to notify the physician of the above changes. Review of a physical therapy visit note on 08/09/2021 at 9:40 AM showed: - The patient had a fall without injury after rolling off the couch; - No documentation of a head to toe assessment; and - No documentation that the agency notified the physician of the fall. During a home visit observation with OT on 08/16/2021 at 2:50 PM, the following was observed: - The patient informed the occupational therapist of having a fall that morning; - The occupational therapist asked the patient about pain or injuries after falling and the patient denied any pain or injuries; - The OT asked the patient if he/she "was bending over" when the fall happened. The patient reported that he/she was not bending over and that he/she "just went down" without any warning; - The patient reported feeling dizzy when sitting or standing up; - The patient was observed to have difficulty sitting up, he/she was falling to the right side; and - The occupational therapist used pillows to prop the patient up to prevent the patient from continuing to fall to the right side. Review of the OT visit note on 08/16/2021 at 2:50 PM, showed, in part: - The patient had an elevated heart rate of 115 beats per minute that was communicated with the registered nurse (RN) case manager A; - The narrative note showed the patient having a fall without injuries or pain, with education provided for the patient to increase activity with attempts at ambulating hourly; - Communication with RN case manager A regarding the patient reporting concerns over recent blood results received from RN case manager A, stating that magnesium levels were not shown on the report; and - The agency failed to notify or document if the physician was informed of the patient falling, having an elevated heart rate, and symptoms that could have caused the fall. During an interview on 08/18/2021 at 10:30 AM, the supervising nurse stated: - The primary care provider's office was contacted by the licensed practical nurse (LPN) on the morning of 08/18/2021 for follow up on the 08/03/2021 hemoglobin level of 7.7; - The physician received the fax from the lab with the results from 08/03/2021 and that the physician faxed orders to the agency to recheck the labs in one week (this would be on or about 08/10/21); - The agency failed to follow up with the primary care provider's office between 08/03/2021 and 08/18/2021 so the agency was unaware that the faxed orders were not received for rechecking labs in one week; and - Staff made a PRN (as needed) visit that day (08/18/2021) to obtain the labs ordered by the physician.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of policy, clinical record review and interview the agency failed to ensure coordination of care delivery to meet the patient's needs in one (Record/Patient #2) of five records reviewed. This deficient practice has the potential to affect the coordination of care and services for all patients on service with the agency. Findings included: Review of the agency's policy titled, "Plan of Treatment," revised February, 2021 showed, in part: - Policy: The patient's plan of care is developed in consultation with physician, clinical staff, patient, and family or significant other, and is documented on the CMS 485 (plan of care); - The written plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals; - The physician and department staff review the plan of care as often as the severity of the patient's condition requires, but at least once every 60 days; - Department clinical staff alert the physician to any changes that suggest a need to modify the plan of care including visit frequency; and - Care will be delivered according to the most recent order. RECORD/PATIENT #2: Review of the plan of care (POC) dated 07/23/2021 through 09/20/2021, showed, in part: - The patient was admitted to home health services on 07/23/2021; and - Diagnoses included encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the digestive system (patient had a blockage that required surgery), malignant neoplasm of unspecified ovary (ovary cancer), secondary neoplasm of liver and intrahepatic bile duct (cancer), anemia in neoplastic disease (low blood), dehydration, sepsis (bacterial infection in the blood), diverticulitis of large intestine without perforation or abscess without bleeding (inflammation in the intestine), hypertension (high blood pressure), fibromyalgia (medical condition of widespread pain), obstructive sleep apnea (periods when breathing stops while sleeping), insomnia (difficulty sleeping), hypokalemia (low potassium levels), hypothyroidism (slow working thyroid), gastro-esophageal reflux disease without esophagitis (indigestion), and constipation (difficulty having bowel movements). Review of the hospital referral dated 07/22/2021 showed: - Multiple physicians involved in the patient's interdisciplinary team that patient had follow up visits scheduled; and - The agency failed to include all physicians in the patient's POC. Review of a skilled nursing note dated 08/03/2021 at 9:50 AM showed: - Blood work was drawn for CBC (complete blood count) and magnesium levels; - Bruising to arms noted without any other detailed documentation as to how the bruising occurred or when bruising happened; - In the physician contacted section of the skilled nurse visit note, "No one contacted as a result of this visit" was documented; and - No coordination of care with case manager. Review of the occupational therapy (OT) note on 08/06/2021 at 8:30 AM showed: - The patient had an elevated blood pressure of 160/90; - No documentation of head to toe assessment or assessment of signs or symptoms; and - No coordination of care with case manager. Review of a skilled nursing note dated 08/06/2021 at 9:20 AM showed: - The patient had a blood pressure of 160/90 (parameters for this top number of 95 to 140 and the bottom number of 60 to 90); - Heart rate (number of times the heart beats in a minute) of 115 beats per minute (parameters of 60 to 100); - Labs were obtained for a basic metabolic panel; - In the physician contacted section of the skilled nurse visit note, "No one contacted as a result of this visit" was documented; - Skilled nurse failed to coordinate care with the case manager; and - The agency failed to notify the physician. Review of a physical therapy (PT) visit note on 08/09/2021 at 9:40 AM showed: - The patient had a fall without injury after rolling off the couch; - No documentation of head to toe assessment; - No coordination of care with the case manager; and - The agency failed to notify the physician. Review of the occupational therapy (OT) note on 08/12/2021 at 9:15 AM showed: - Missed visit documented with physician being made aware; and - No coordination of care with case manager. Review of the OT visit note on 08/16/2021 at 2:50 PM, showed, in part: - The patient had an elevated heart rate of 115 beats per minute that was communicated with the registered nurse (RN) case manager A; - The narrative note showed the patient having a fall without injuries or pain, with education provided for the patient to increase activity with attempts at ambulating hourly; - Communication with RN case manager A regarding the patient reporting concerns over recent blood results received from RN case manager A, stating that magnesium levels were not shown on the report; and - The agency failed to notify the physician of the patient falling, having an elevated heart rate, and symptoms that could have caused the fall. During a phone interview with the primary care physicians nurse on 08/17/2021, the following was stated: - The patient has other physicians that are providing care and orders for the patient; - The patient is being followed by an oncologist; and - The patient's last physician follow up appointment was with the patient's surgeon. On 08/18/2021 at 10:30 AM, the supervisory nurse stated: - The licensed practical nurse (LPN) contacted the primary care provider's office on the morning of 08/18/2021 for follow up on the 08/03/2021, hemoglobin level of 7.7; - The physician received the fax from the lab with the results from 08/03/2021 and that the physician had faxed orders to the agency to recheck the labs in 1 week; - The agency never received the fax with orders from the physician and that the physician's office refaxed the order on 08/16/2021 after the follow up call was finally made by the LPN; and - A PRN (as needed) visit was being made that day (08/16/2021) to obtain the labs the physician ordered to be rechecked.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, record review, and interview, the agency failed to ensure staff provided ongoing education and training to the patient in, but not limited to, one (Record/Patient #2) of five records reviewed. This deficient practice has the potential to affect all patients served by the home health agency. Findings included: Review of the agency's policy titled, "Medication Management," revised February, 2021 showed, in part: - During return visits, the SN will teach medication actions, side effects, dosages, and write on a medication sheet any pertinent or helpful information; - At each visit the SN will reconcile any/all new or changed medications and update the medication list at that time; - The nurse will evaluate on admission, re-certification, resumption of care, return visits, as appropriate to care, and discharge each of the drugs for proper dosage, patient allergies, potential adverse reactions, ineffective drug therapy, significant side effects, patient's perception of side effects and efficacy, significant drug interactions, duplicate drug therapy, non-compliance with drug therapy, and patient and caregiver knowledge of the drugs; - The nurse will refer to information from the patient's medical record, relevant laboratory results, clinical response, and medication profile; and - The nurse will monitor the patient's response to the first dose of a medication new to a patient at the return visit or sooner as the condition of the patient warrants. RECORD/PATIENT #2: Review of the plan of care (POC) dated 07/23/2021 through 09/20/2021, showed, in part: - The patient was admitted to home health services on 07/23/2021; and - Diagnoses included: Encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the digestive system (patient had a blockage that required surgery), malignant neoplasm of unspecified ovary (ovary cancer), secondary neoplasm of liver and intrahepatic bile duct (cancer), anemia in neoplastic disease (condition when the body stops producing enough blood cells), dehydration, sepsis (bacterial infection in the blood), diverticulitis of large intestine without perforation or abscess without bleeding (inflammation in the intestine), hypertension (high blood pressure), fibromyalgia (chronic medical condition that affects the muscles and soft tissue causing widespread pain), obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), insomnia (difficulty sleeping), hypokalemia (low potassium levels), hypothyroidism (slow working thyroid), gastro-esophageal reflux disease without esophagitis (indigestion), and constipation (difficulty having bowel movements). Review of clinical record showed: - New medication orders on 07/30/2021 for calcium plus vitamin D 600 mg (milligrams)/500 IU (international units) 1 tab daily, magnesium oxide 400 mg 1 tablet daily; may decrease to half a tablet as needed for loose stools, potassium chloride 20 mEq (milliequivalent) 1 tablet daily for 7 days, and levothyroxine sodium 112 mcg (micrograms) 1 tablet daily; - Documentation failed to include if patient received education on the new medications ordered on 07/30/2021; - Labs were obtained on 08/03/2021 and 08/06/2021 and no education was documented/provided during any skilled nurse visits regarding the lab results; - Patient noted to have elevated blood pressure and heart rate during skilled nurse visits on 08/06/2021 and 08/13/2021, no education was provided/documented regarding signs and symptoms to monitor and report; and - No education provided/documented regarding signs and symptoms to monitor and report regarding the labs obtained on 08/03/2021 with the hemoglobin (protein in the blood that carries oxygen from the lungs to the rest of the body) level of 7.7 (normal range is 10.4 to 15.9), hematocrit (the percentage of red blood cells in the body) level of 24.0 (normal range is 31.0 to 47.0), magnesium (mineral that is crucial to the body's function) of 1.18 (normal range is 1.30 to 2.10), and sodium (helps body keep fluids in a normal balance) level of 133 (normal range is 136 to 145) obtained on 08/06/2021. A home visit observation on 08/16/2021 at 3:30 PM showed the agency failed to ensure ongoing patient education and training by: - Patient concerned over not knowing the results of the magnesium lab obtained on 08/06/2021; - Patient required frequent lab monitoring while hospitalized due to abnormal results that required interventions of medication adjustments; - Patient's spouse expressed concerns of not knowing if the patient needed to make adjustments with medications based on the lab results; and - Patient unaware of plans for future labs and monitoring until results return to normal. During an interview on 08/17/2021 at 10:00 AM, Case Manager A acknowledged the patient's concerns and agreed to provide blood draw results and education to the patient at the next nursing visit.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of a copy of the patient rights contained in the admission folder left in the patient's home, home visit observation, complaint log, and interview, the agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in two (Record/Patient #2 and #3) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the Center for Medicare and Medicaid Services Conditions of Participation: Patient's Rights 484.50 (c) (4) found in the admission folder left in patient's homes at time of admission to service showed: - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to, (but not limited to) the disciplines that will furnish care and the frequency of visits. Review of the agency's complaint log on 08/16/2021 showed: - Two agency investigated complaints related to conflicting or missed visit times for two patients; - On 11/13/2019, the caregiver spoke with the director of home health, stated he/she verbalized with several clinicians that the patient had three physician appointments on this date and the clinicians still called and tried to set up times to see the patient. The care giver felt the clinicians needed to communicate better. The director of home health informed the patient that clinicians needed to communicate better and he/she spoke with all disciplines. The disciplines verbalized understanding and stated they would do better with correlating time around all appointments a patient had and that the caregiver was instructed that the agency staff would not let this happen again; and - On 06/18/2020, the vice president of nursing emailed the director of home health about a complaint from a caregiver related to past experience with home health that visits conflicted with appointment times for the patient and it was blamed on the patient. The director explained the agency protocol on notification of patients regarding visit times and nursing assessment protocol. The care giver was given the option of changing nurses but declined. The care giver verbalized understanding of the protocol and had the ability to contact the director if needed. RECORD/PATIENT #2: During a home visit on 08/16/2021 at 2:45 PM, the home admission folder reviewed by the surveyor showed: - A copy of the Condition of Participation: Patient Rights; and - A blank monthly calendar. During an interview on 08/16/2021 at 3:32 PM, the patient stated the problem was that he/she did not know who was coming to visit and on what days. RECORD/PATIENT #3: During a home visit observation and interview on 08/17/2021 at 10:30 AM, the home admission folder was not in the home and the patient stated that: - He/she had an admission folder but did not know what happened to the folder or where it was located; and - No written schedule was left in the home but staff told him/her at the end of a visit or called him/her to say when they were to make a visit. During an interview on 08/17/2021 at 3:30 PM, the supervisory nurse stated that: - Staff tell patients during their visit when they will return for a visit or they call and tell the patient; and - There are times when staff need to change visits so they will call the patient to let him/her know.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation, and interview, the agency failed to provide in writing the name and contact information of the clinical manager in, but not limited to, one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: The agency did not provide a policy related to clinical manager's contact information to be left in the patient's home folder. RECORD/PATIENT #2: During a home observation visit on 08/16/2021 starting at 2:50 PM with OT (Occupational therapist) C, the surveyor observed the patient's home folder. The agency failed to provide in writing the name of the current clinical manager. On 08/16/2021 at 3:30 PM, during an interview with OT C regarding who the clinical manager was, the OT C reported that Case Manager B was the clinical manager. During an interview on 08/17/2021 @ 9:30 AM, Case Manager B reported that she/he had not been the clinical manager since 07/19/2021.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on agency policy review, observation, and interview, the agency failed to put in place a program/procedure for screening for patients prior to home visits, and for visitors/non-employees for COVID-19 (pandemic infection) who entered the home health agency office. This deficient practice has the potential to affect infection control needs for all visitors/non-employees, employees, and patients served by the agency. Findings included: Review of the undated policy titled, "Coronavirus Plan," provided by the agency did not show a plan for the home health agency to screen visitors/non-employees for COVID-19 signs and symptoms (S&S). The Coronavirus Plan provided, was geared for the hospital patient who presented to the emergency room, ambulatory care, or clinic settings. Review of the agency's policy titled, "Infection Control/Surveillance," reviewed February, 2021 showed: - The infection prevention plan addresses the identification and reduction of the risks acquiring and transmitting infections among patients, team members, physicians, and others associated with the agency. Ongoing surveillance identifies areas where renewed or increased focus is needed. Personnel will document and report infections present at the time of admission and/or which develop while the patient is on home care services. - The admitting nurse will assess the patient for S&S of infection and for any recent history of infection per referral data and interview; - The nurse will document assessment of infection and infection history within the comprehensive admission assessment; - The nurse will educate the patient on ways to control the spread of infection in the home and community, as well as prevention of other infections; - The policy did not address COVID-19 specifically; and - The policy did not address the surveillance of staff, visitors, or non-employees for S&S of COVID-19. Observation during all days of the survey (08/16/2021 through 08/18/2021) showed the agency did not screen the surveyors for S&S of COVID-19. The agency did not post any information related to COVID-19 on the entrance door but did post signage that a mask was to be worn to enter the agency. During an interview on 08/17/2021 at 8:30 AM, Case Manager A stated that the secretary called patients prior to entry of the patient's home to tell of the approximate time of arrival of the staff to make a visit and asked COVID-19 questions. He/she then informs staff if the patient was symptomatic. During an interview on 08/17/2021 at 9:35 AM, the office supervisor stated that: - The receptionist was on leave for vacation and then diagnosed with COVID-19. He/she usually calls and records in a log book answers to COVID-19 questions of all patients seen on a given day. The office scribe worked in the receptionist place and he/she was not instructed to do the monitoring of patients. An observation on 08/17/2021 at 9:35 AM of the log book for COVID-19 monitoring of patients showed no documented monitoring/calls of patients for COVID-19 symptoms since 08/04/2021. During an interview on 08/17/2021 at 3:00 PM, the office manager stated that: - The hospital told the agency that monitoring did not have to be done and monitoring of employees stopped about one year ago; - The agency did not have visitors or non-employees enter the office; - He/She provided an undated email from the hospital infection preventionist that stated: "During our weekly COVID-19 Task Force meetings, it was decided, after an informal, continuous risk assessment that spanned over the course of 6+ months, that our facilities would not continue to perform temperature checks at entry points, due to the inaccuracies of temperatures, the nature of the disease process, and the stress added to our already reduced workforce, this form of assessment was discontinued. Many patients we have seen, and treated have been positive for COVID-19 and have been afebrile (no increased temperature). We used several different types of thermometers to try to rule out inaccuracies, however it was consistently noted that the temperature changes outside our facility affected body temperatures of those individuals coming through our doors. We concluded based on this informal assessment that the most reliable method was self-assessment and the honor system of those individuals. We underwent a Hospital State survey in September, 2020, where this was discussed and determined to be working appropriately and effectively for our facility." - Provided to the surveyor, Admissions with COVID forms, which showed from 01/01/2020 through 08/17/2021 a total of 94 patients with COVID-19 were admitted to home health services; and - The agency had five current patients diagnosed with COVID-19.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on agency policy review, home visit observation, clinical record review, and interview, the agency failed to document education provided for COVID-19 in the clinical record for one (Record/Patient #3) of three home visit clinical records reviewed. This deficient practice has the potential to affect infection control needs for all visitors/non-employees, employees, and patients served by the agency and newly admitted patients served by the agency. Findings included: Review of the undated policy titled, "Coronavirus Plan," provided by the agency, did not show a plan for the home health agency to screen visitors/non-employees for COVID-19 signs and symptoms (S&S). The Coronavirus Plan provided was geared for the hospital patient who presented to the emergency room, ambulatory care, or clinic settings. Review of the agency's policy titled, "Infection Control/Surveillance," reviewed February, 2021 showed: - The infection prevention plan addresses the identification and reduction of the risks acquiring and transmitting infections among patients, team members, physicians, and others associated with the agency. Ongoing surveillance identifies areas where renewed or increased focus is needed. Personnel will document and report infections present at the time of admission and/or which develop while the patient is on home care services. - The admitting nurse will assess the patient for S&S of infection and for any recent history of infection per referral data and interview; - The nurse will document assessment of infection and infection history within the comprehensive admission assessment; - The nurse will educate the patient on ways to control the spread of infection in the home and community, as well as prevention of other infections; and - The policy did not address COVID-19 specifically. RECORD/PATIENT #3: Review of the clinical record showed: - Start of care date: 07/12/2021; - Diagnoses included, but not limited to: Disruption (opening) of surgical wound, bacteremia (infection in the blood stream), pneumonia due to Escherichia coli (bacteria normal to the bowel), and acute respiratory failure; - Interventions included but not limited to: Teach patient/caregiver measures to reduce risk and avoid infection, reporting of S&S for infection, and standard infection precautions (hand hygiene, use of personal protection equipment (PPE)- gloves, masks, eyewear, respiratory hygiene/cough etiquette, sharps safety, safe injection practices, and sterile instruments/devices); handwashing and cough etiquette; and - Interventions did not include specifics related to COVID-19. Review of the start of care initial assessment dated 07/12/2021 showed: - Other infection assessment: Bacteremia; - Location: Blood stream; - Antibiotics: Yes; - Isolation measures: No; - Infection precautions used: Disinfection, hand hygiene, PPE, proper use/disposal of equipment/supplies, and respiratory hygiene/cough etiquette; - Infection control/Universal precautions (an approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV (AIDS), hepatitis B, or other blood borne pathogens); and - Did not include documented assessment of or education/review of COVID-19 S&S and monitoring for S&S. Review of all subsequent skilled nurse visits from 07/14/2021 through 08/13/2021 did not include documented education on COVID-19 monitoring and S&S. During a home visit observation on 08/17/2021 at 10:30 AM, Case Manager A did not instruct the patient on monitoring or S&S of COVID-19. During an interview on 08/17/2021 at 3:20 PM, the intake coordinator stated that: - Staff documented patient/caregiver education as infection control, respiratory symptoms but not as COVID-19 specifically; and - All admission packets included a COVID-19 pamphlet.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review, and interview, the agency failed to maintain professional standards according to their agency policy when wound measurements were not performed and recorded in the clinical record and staff did not follow physician's orders to change the wound dressing every 72 hours for one (Record/Patient #5) of six clinical records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Skin and Wound Assessment and Management," revised 02/2021 showed: - Policy: All home care patients will receive a comprehensive skin assessment on admission to home care, during resumption of care, and recertification visits. All home health staff will document the patient's skin/wound assessment as appropriate to care. - On admission to home care, the skilled nurse (SN) will complete an initial skin assessment and document utilizing the Braden Scale (a scale for predicting pressure ulcers, wounds developed over bony prominence's); - Protocols will be placed on the plan of care to care for the wounds; - Evaluation and treatment measures will be performed and documented at each return visit; - Measure wound (s) at least weekly and as needed for significant change in condition; and - The wound measurements and status will be documented in the care plan. RECORD/PATIENT #5: Review of the plan of care (POC) dated 07/12/2021 through 09/09/2021 showed: - Diagnoses included but not limited to: Stage 2 (Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; may also present as an intact or open/ruptured blister filled with serum or serosanguineous fluid may present as a shiny or dry shallow ulcer without slough or bruising), pressure ulcer to left buttock, and Stage 3 (Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not exposed, some slough (dead tissue) may be present) pressure ulcer to right buttock. - SN assess and evaluate 07/12/2021 through 07/26/2021, then 1 w 1 (1 time per week for 1 week), 2 w 3, and 1 w 4, 3 PRN (as needed) visits; - Friction sheer (when the epidermis or top layer of skin separates from the dermis or bottom layer of skin, this is what is often referred to as a 'rug burn') to lower back, SN to apply skin barrier cream BID (twice daily) and PRN; - Pressure injury to left and right buttocks: Perform hand hygiene, remove soiled dressing with proper technique, change dressing every 72 hours and PRN, cleanse with mild soap/water, pat dry, cover with optifoam (highly absorbent and conformable dressing that can manage repeated bacteria introduction, while ionic silver provides an antimicrobial barrier against bacteria) dressing; and - Failed to address measuring of wounds. Review of the start of care comprehensive assessment dated 07//12/2021 showed the SN measured the right and left pressure ulcer wounds. Review of the Wound Flow Sheet from 07/12/2021 through 08/10/2021 showed: - SN saw the patient on 07/15/2021 and did not make another visit until 96 hours later rather than the ordered 72 hours for dressing change when he/she saw the patient on 07/20/2021; - No wound measurements for the left and right buttock pressure ulcers for the dates of 07/20/2021 and 07/23/2021; - No wound measurements for the left and right buttock pressure ulcers for the dates of 07/26/2021 and 07/29/2021; and - No wound measurements for the left and right buttock pressure ulcers for the dates of 08/02/2021 and 08/05/2021. During an interview on 08/18/2021 at 10:00 AM, the supervisory nurse stated wound measurements are taken weekly, usually on Mondays.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview the agency failed to ensure that skilled professional services clinical notes contained documentation according to agency policy in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect the documentation of all of the agency patients. Findings included: Review of agency policy titled, "Documentation" and revised 02/2021 showed, in part, that visit notes will be submitted electronically before the end of the day the visit was made. RECORD/PATIENT #2: Review of the plan of care (POC) dated 07/23/2021 through 09/20/2021, showed, in part: - The patient was admitted to home health services on 07/23/2021; and - Diagnoses included: Encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the digestive system (patient had a blockage that required surgery), malignant neoplasm of unspecified ovary (cancer of the ovary), secondary neoplasm of liver and intrahepatic bile duct (cancer), anemia in neoplastic disease (condition when the body stops producing enough red blood cells), dehydration, sepsis (bacterial infection in the blood), diverticulitis of large intestine without perforation or abscess without bleeding (inflammation in the intestine), hypertension (high blood pressure), fibromyalgia (chronic medical condition that affects the muscles and soft tissue causing widespread pain), obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), insomnia (difficulty sleeping), hypokalemia (low potassium levels), hypothyroidism (slow working thyroid), gastro-esophageal reflux disease without esophagitis (indigestion), and constipation (difficulty having bowel movements). Review of the clinical record showed: - Documentation from the skilled nurse visit, made on 07/27/2021 at 8:29 AM, was not completed until 08/01/2021 at 10:35 PM; - Documentation from the skilled nurse visit, made on 07/30/2021 at 10:46 AM, was not completed until 08/02/2021 at 10:38 PM; - Documentation from the skilled nurse visit, made on 08/03/2021 at 9:50 AM, was not completed until 08/10/2021 at 6:52 PM; and - Documentation from the skilled nurse visit, made on 08/06/2021 at 9:20 AM, was not completed until 08/10/2021 at 7:19 PM. During an interview with the supervisory nurse on 08/17/2021 at 4:30 PM, the supervisory nurse reported that documentation was to be completed in 24 hours from time of the visit.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: Care planning, coordination of services and quality of care; and Organization and administration of services. The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 08/23/2023.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on policy review, job description review, record review, observation, and interviews, the agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to show adequate governing body and administrative oversight to patients resulting in two condition level citations: - 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care; and - 484.105 Condition of Participation: Organization and Administration of Services. The agency, administrator, and the governing body failed to: - Ensure the administrator was appointed by and reported directly to the governing body (G946); - Ensure the parent agency had administrative control of the branch location and that the branch location was a functioning branch (G974); and - Ensure all services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice (G984). The cumulative effect of these systemic practices resulted in the agency's inability to ensure the patient's care needs would be met.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on policy review, review of agency administrative information, observation, and interview, the agency failed to ensure an administrator was appointed by and reported directly to the governing body. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: Review of the agency's policy, "Administrative Roles," approved on 03/04/2021 by the previous administrator showed: - The home health agency administrator, appointed by the healthcare system board, is responsible for the home health agency; - The home health agency administrator will also function as the director of the home health agency with full responsibility of day to day activities and operations of the department. This individual will report to Hannibal Regional Healthcare System CEO with indirect reporting to vice-president of nursing; - All home health clinical and support staff will report directly to the director of the home health agency, or in his or her absence to the designated supervisor; and - In the absence of the home health agency administrator/director of home health agency, the supervisory nurse or quality coordinator/unit educator will assume the responsibilities of the department with support given by the CEO and vice president of nursing. Review of the agency's organization chart showed the former director of home health (administrator) listed. During the entrance interview on 08/16/2021 at 12:45 PM, the supervisor/quality management registered nurse of the hospital said the vice president of nursing will be the administrator when he/she is approved by the board of directors on "08/24/2021". The vice president of nursing was currently out on medical leave but was available by phone. During an interview on 08/16/2021 at 12:27 PM, the supervisory nurse (clinical manager) stated they had no administrator and he/she reports to the nursing administrator of the hospital. During an interview on 08/16/2021 at 3:32 PM, the office supervisor stated the previous administrator had quit two weeks ago on 07/31/2021. During an interview on 08/17/2021 at 4:18 PM, the office supervisor and supervisory nurse stated the previous administrator quit on 07/31/2021. The vice president of nursing hasn't worked home health but would be the interim administrator once the board meets on "08/26/2021". The vice president of nursing does case conferences once a week and the previous administrator was at the agency all the time. During interview on 08/18/2021 at 11:10 AM the vice president of nursing stated he/she was the interim administrator. The previous administrator had left and there was no succession plan in place so he/she becomes the interim administrator until an administrator is hired. They were in the process of getting board approval and the board has not met yet.

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on review of the home health agency reciprocal agreement between the states of Missouri and Illinois, observation, and interview, the agency failed to ensure the parent home health agency provided direct support and administrative control of its branch location in Hull, Illinois by assuring the branch was operational and provided the same services as the parent home health agency. This deficient practice has the potential to affect all patients served by the branch location. Findings included: Review of the Home Health Agency Reciprocal Agreement Between the States of Missouri and Illinois, signed by the Illinois acting division chief on 07/17/2002 and the Missouri director on 05/02/2002, showed, in part, the states of Missouri and Illinois, in order to administer more effectively the responsibilities relating to practice locations of Home Health Agencies (HHA) that operate across state lines, agree each state will be responsible for ensuring that respective state licensure laws and any other state requirements relating to the home health agency are met. During observation and interview on 08/16/2021 at 4:00 PM showed: - The Hannibal Regional Home Health Agency had a building located in Hull, Illinois; - Hannibal Regional Hospital Home Health was marked on the two side windows; - The front door read "For Assistance Call 800/981/4442, 24 hours a day; - A piece of paper was taped to the front door that showed, "Hannibal Mobile Diagnostics, we are currently out of the office. Please call (573)248-5123 for assistance"; - No hours were posted; - Covid information was taped to the front door; - There was no staff in the office, there was a desk, a two door filing cabinet, a chair, and a telephone was on the desk; - The number posted for the home health company was answered by the hospital; and - The number posted for Hannibal Mobile Diagnostics was answered by an employee who said he/she worked for Hannibal Mobile Diagnostics and the Hull, Illinois office is never used. Review of the most recent professional advisory committee meeting dated 10/15/2020 showed no information regarding the Illinois branch office. During the entrance interview on 08/16/2021 at 12:45 PM the supervisory/quality management registered nurse stated there is a branch office in Hull, Illinois. The branch office is mainly used for storage and no staff work from the office. During an interview on 08/17/2021 at 3:15 PM the supervisory nurse said the agency has patients in Illinois. The branch office in Illinois has not been open for at least six years that he/she knew of. During an interview on 08/18/2021 at 10:21 AM and 12:54 PM the office supervisor stated: - The Illinois branch office has never ran as a home health agency; - He/she drives over there to update the license; - Maintenance goes to the branch office once a month for preventative maintenance; - There were just old records at the branch office, before electronic medical records (EMR); - The phone number provided for the Illinois branch office rolls over to the hospital; - The vice president of nursing services, who is the interim administrator, does not have an Illinois license, so there is no administrator over the Illinois branch office at this time; - They have Illinois patients but everything is managed out of the Missouri office; and - Their branch office operates under the same policy and procedures as the parent office. During a telephone interview on 08/18/2021 at 11:10 AM, the vice president of nursing services stated the Illinois office was not active and the Illinois patients were managed through the Missouri home health agency. He/she was the interim administrator for the home health agency.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of the Missouri State Licensure rules and statutes, and review of the Illinois Complied Statutes, Professions, Occupations, and Business Operations Nurse Practice Act, policy review, personnel file review, and interview, the agency failed to request and obtain current nursing licensure in the state of Illinois and failed to obtain results of findings of the Family Care Safety Registry (FCSR) for one (Employee #5), the vice president of nursing, of five employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the Illinois Complied Statutes, Professions, Occupations, and Business Operations (225 ILCS65/50-5, Nurse Practice Act, effective 10/05/2007 showed: - Sec. 50-5 Legislative Purpose: The practice of professional and practical nursing in the State of Illinois us hereby declared to affect the public health, safety, and welfare and to be subject to regulation and control in the public interest. It is further declared to be a matter of public interest and concern that the practice of nursing, as defined in the Act, merit and receive the confidence of the pubic and that only qualified persons be authorized to so practice in the State of Illinois; - Sec.50-10 Definitions: "Registered Nurse" or "Registered Professional Nurse" means a person who is licensed as a professional nurse under this Act and practices nursing as defined in this Act. Only a registered nurse licensed under this Act is entitled to use the titles of "registered nurse" and "registered professional nurse" and the abbreviation "R.N."; - "Registered professional nursing practice" means a scientific process founded on a professional body of knowledge that includes, but is not limited to, the protection, promotion, and optimization of health and abilities, prevention of illness and injury, development and implementation of the nursing plan of care, facilitation of nursing interventions to alleviate suffering, care coordination,, and advocacy in the care of individuals, families, groups, communities, and populations.; - Sec. 50-15 Policy, application of Act: (a) For the protection of life and the promotion of health, and the prevention of illness and communicable diseases, any person practicing or offering to practice advanced, professional, or practical nursing in Illinois shall submit evidence that he or she is qualified to practice, and shall be licensed as provided under this Act. No person shall practice or offer to practice advanced, professional, or practical nursing in Illinois or use any title, sign, card, or device to indicate that such a person is practicing professional or practical nursing unless such person has been licensed under the provisions of this Act; - This Act does not prohibit the following: (9) The practice of professional nursing by one who is a registered professional nurse under the laws of another United States jurisdiction or a foreign jurisdiction and has applied in writing to the Department, in form and substance satisfactory to the Department, for a license as a registered professional nurse and who is qualified to receive such license under Section 55-10, until (1) the expiration of six months after the filing of such written application, (2) the withdrawal of such application, or (3) the denial of such application by the Department. Review of the Joint Committee on Administrative Rules, Administrative Code, Title 68: Professions and Occupations, Chapter VII: Department of Financial and Professional Regulation, Subchapter b: Professions and Occupations, Part 1300 Nurse Practice Act, Section 1300.20: Nursing Delegation by a Registered Professional Nurse showed: - Section 1300.20 Nursing Delegation by a Registered Professional Nurse: - a) "Community-Based Setting" means facilities within the community where individuals, groups and populations may seek or receive assistance and/or care. These include, but are not limited to, schools, assisted living facilities, physicians' and APRN's (Advanced Practice RN) offices, clinics, home health, and residences where individuals receive services under the Home Health, Home Services, and Home Nursing Licensing Act [210 ILCS 55] or Hospice Program Licensing Act [210 ILCS 60]. Community-Based setting does not include Home Services Agencies and Home Service Placement Agencies; - "Delegation" means transferring to a specific individual the authority to perform a specific nursing intervention, in a specific situation; - "Predictability of outcomes" means that a registered professional nurse or advanced practice nurse has determined that the patient's or individual's clinical status is stable and expected to improve or the patient's or individual's deteriorating condition is expected to follow a known or expected course; - "Stability" means a registered professional nurse or advanced practice registered nurse has determined that the individual's clinical status and nursing care needs are consistent (Section 50-75 (a) of the Act); - b) "A registered professional nurse may: 1) Delegate nursing interventions to other registered professional nurses, licensed practical nurses, and other unlicensed personnel. The delegation should be based on the comprehensive nursing assessment that includes, but is not limited to: A) The stability and condition of the patient; B) The potential harm; C) The complexity of the nursing intervention to be delegated; D) The predictability of outcomes; and E) The competency of the person to whom the nursing intervention is delegated. To ensure competency, the RN may have to provide instruction to the individual or evaluate the individual's experience, training and/or education; - c) In community-based or in-home settings, and RN may: 1) Delegate medication administration (limited to oral or subcutaneous (under the skin) dosage and topical or transdermal application) to unlicensed personnel, if the conditions of delegations set forth in subsection (b) are met; 2) Delegate, guide and evaluate the implementations of nursing interventions as a component of patient care coordination after completion of the comprehensive assessment based on analysis of the comprehensive nursing assessment data. Care coordination may occur in person, by telecommunication, or electronic communication, (Section 5-75 (b) of the Act); - Section 1300.10 Definitions: - "Registered Nurse", "Registered Professional Nurse", or "EN" means a person who is licensed as a professional nurse under the Act and practices nursing as defined by the Act; and - Source: Amended at 45 Ill. Reg. 228, effective January 4, 2021. Review of Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of the hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of the agency's policy titled "Administrative Policy", revised 03/16/2018, showed: - Purpose: To provide for recruitment and processing of qualified and competent team members; - Reference checks and background checks will be conducted by human resources; - Criminal background checks are completed on all selected external candidates for employment; - All current team members transferring to and selected external candidates hired to work in home health will have a FSCR background screening completed; and - Licensure/Certification: Human resources will verify credentials through primary source verification, for all new or transferring team members being selected in positions requiring such credentials; and - This will be accomplished prior to the offer of employment. Review of https://nurse.org showed the Nursing Licensure Compact (NLC) is an agreement between states that allows nurses to have one license but the ability to practice in other states that are part of the agreement. The NLC did not list Illinois as a compact state. Review of the current patient list for the Illinois branch office associated with the agency showed nine current patients. EMPLOYEE #5 (E5): Review of the personnel file on 08/17/2021 showed: - Date of hire: 06/18/2015; - Position: Vice president of nursing for hospital; interim administrator; - No patient visits/contact in home health; - A current Missouri nursing license with an expiration date of 04/30/2023; - No evidence of an Illinois nursing license; and - No evidence of the FCSR. During an interview on 08/17/2021 at 3:00 PM, the office supervisor stated that the vice president of nursing/interim administrator did not have an Illinois nursing license because he/she did not see patients. During an interview on 08/18/2021 at 9:07 AM, the human resource specialist (HRS) stated that: - All required information for background checks and employee disqualification list (EDL) should be requested and received prior to hire of the employee; - E5 did not have a FCSR or an Illinois nursing license and he/she did not know why. During an interview on 08/18/2021 at 10:21 AM, the office supervisor stated that the vice president of nursing/interim administrator did not have an Illinois nursing license so therefore the Illinois branch office did not have an administrator (to oversee patients in Illinois).

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and interview, the agency failed to ensure a complete comprehensive discharge summary containing relevant information was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's discharge for two (Records/Patients #5 and #6) of two discharge records reviewed and the agency failed to ensure a transfer summary was sent to the receiving health care facility within two business days of becoming aware of an unplanned transfer in one (Record/Patient #3) of one transfer record reviewed. This deficient practice has the potential to affect all discharged or transferred patients served by the agency. Findings included: Review of the agency's policy titled, "Discharge/Transfer from Home Care Services," revised 02/2021, showed in part: - A discharge summary will be completed and sent to the physician; - An updated medication list will be sent to the physician upon discharge; - Discharge summaries will be completed within 48 hours of dismissal of a patient; - An agency discharge summary will be completed on every patient discharged from the agency and will represent all disciplines involved in the plan of care; and - Patients will only be transferred or discharged for but limited to: when it is necessary for the patient's welfare. The policy failed to address what information or when a transfer summary should be sent or to whom the summary should be sent. Review of the Condition of Participation: Clinical Records 484.110(a)(6) Interpretive Guidelines states: - Discharge summaries typically contain the following items: Admission and discharge dates, physician responsible for the home health plan of care (POC), reason for admission to home health, type of services provided and frequency of services, laboratory data, medications the patient is on at time of discharge, patient's discharge condition, patient outcomes in meeting the goals in the POC, and patient and family post-discharge instructions; and - The contents of the transfer summary typically contains the same components as the discharge summary. RECORD/PATIENT #6: Review of the discharge summary dated 08/12/2021 showed the patient: - Was discharged on 08/12/2021; - The reason for admission was blank; - The patient's discharge condition was blank; - The patient/family discharge instructions was blank; and - There was no evidence to show the discharge summary and medication list was sent to the physician. During an interview on 08/17/2021 at 3:15 PM, the supervisory nurse stated the agency sends the discharge summary to the physician within five business days. The written discharge instructions are left in the patient's home. The summary was sent to the physician and there was no evidence to show when the discharge summary was sent. No further information was provided. RECORD/PATIENT #5: Review of the POC dated 07/12/2021 through 09/09/2021 showed: - Start of care date: 07/12/2021; - Diagnoses included but not limited to: Surgery to circulatory system, fracture of left femur, pressure ulcers to buttocks, and history of falls; - Skilled nursing (SN): 1 w 1 (1 time per week for 1 week), 2 w 3, 1 w 4, and 3 PRN (as needed visits); - Physical therapy (PT): 1 w 1 and 2 w 3; - Occupational therapy (OT): 1 w 1, and 2 w 3; - Discharge: Return to independent level of care. Review of the discharge OASIS (federally mandated assessment tool) dated 08/10/2021 showed: - Patient no longer homebound; - Patient reported to start outpatient therapy; - Physician's office notified by phone of discharge from agency. Review of the discharge summary dated 08/10/2021 showed: - Discharge effective date: 08/10/2021; - All disciplines discharged; - Did include a comprehensive summary of care for the patient for the episode of care dated 07/12/2021 through 08/09/2021 to include all disciplines. - Sent to the physician on 08/10/2021. RECORD/PATIENT #3: Review of the POC dated 07/12/2021 through 09/09/2021 showed: - Diagnoses included but not limited to: Disruption (opening) of surgical wound, bacteremia (infection in the blood stream), pneumonia due to Escherichia coli (bacteria normal to the bowel), and acute respiratory failure; - SN: Assess and evaluate 07/12/2021 through 07/26/2021; - SN: 2 w 1, 3 w 8, and 3 PRN visits; - PT: Assess and evaluate 07/13/2021 through 07/27/2021; and - OT: Assess and evaluate 07/13/2021 through 07/27/2021. Review of a SN visit note dated 07/26/2021 showed: - SN contacted patient's family member, patient in the emergency room (no reason or explanation documented); - Physician made aware; and - No further actions needed. Review of the transfer OASIS dated 07/26/2021 showed: - Transfer reason: Decline in health, (no further explanation of need for transfer); - Patient transferred to an inpatient facility, not discharge from the agency; and - Patient admitted due to post-operative complications. Review of the clinical record showed no transfer summary completed or sent to the admitting facility within two business days of becoming aware of the transfer and admission to the receiving facility. During an interview on 08/17/2021 at 3:20 PM, the intake coordinator stated that: - He/she sends a transfer care summary that includes a medication profile, plan of care, communication notes, but he/she does not send a comprehensive summary of care to include each discipline; - Nothing was sent to the physician or admitting facility related to the transfer of Patient #3; - He/she does not make a copy or have documentation of the transfer summary to show when the summary is sent to the admitting facility; and - The summary is only sent to the admitting facility.