Every finding on record at Harrison County Home & Public Health

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 8/19/24 through 8/21/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 8/19/24 through 8/21/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 44 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, agency staff interviews, clinical record reviews and agency policy reviews, the agency failed to complete a drug regimen review with each comprehensive assessment and failed to identify patient specific medications issues for 4 of 7 sampled patients (Patients #2, #3, #4 and #5). Failure to ensure medications were reviewed at the time of each comprehensive assessment, using a current and accurate list of medications taken by the patient at the time of the assessment, increased the potential for unidentified medication interactions, patient noncompliance, ineffective medication therapy, duplicate drug therapy and side effect risks to the patient. Findings include: 2. Patient #2 had a start of care date of 11/20/23. Clinical record review revealed the following: a. The plans of care (POCs), dated 5/8/24 to 7/16/24 and 7/17/24 to 9/14/24, included orders for medications. b. The comprehensive assessment, dated 7/15/24, completed by Staff D, Registered Nurse (RN), included documentation a DRR completed. The DRR lacked review of ineffective drug therapy, significant side effects, duplicate rug therapy and noncompliance with drug therapy. The agency failed to complete a drug regimen review with all comprehensive assessments. 3. Patient #3 had a start of care date of 8/16/24. Clinical record review revealed the following: a. The POC, dated 8/16/24 to 10/14/24, included orders for medications. b. The comprehensive assessment at the start of care, dated 8/16/24, completed by Staff B, Clinical Manager, included documentation a DRR completed. The DRR lacked review of ineffective drug therapy, significant side effects, duplicate rug therapy and noncompliance with drug therapy. The agency failed to complete a drug regimen review with all comprehensive assessments. 4. Patient #5 had a start of care date of 5/17/24. Clinical record review revealed the following: a. The plans of care (POCs), dated 5/17/24 to 7/15/24 and 7/16/24 to 9/13/24, included orders for medications. b. The comprehensive assessment completed at start of care, dated 5/17/24, completed by Staff B, Clinical Manager, included documentation a DRR completed. The DRR lacked review of ineffective drug therapy, significant side effects, duplicate rug therapy and noncompliance with drug therapy. c. The comprehensive assessment, dated 7/11/24, completed by Staff B, Clinical Manager, included documentation a DRR completed. The DRR lacked review of ineffective drug therapy, significant side effects, duplicate rug therapy and noncompliance with drug therapy. The agency failed to complete a drug regimen review with all comprehensive assessments. The above findings shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, Licensed Practical Nurse (LPN). According to the agency policy titled Comprehensive Assessment, dated 5/2023, the comprehensive assessment will include a drug regimen review (DRR) that identifies potential medication drug reactions including ineffective drug therapy, significant side effects, drug interactions, duplicate drug therapy and noncompliance with drug therapy. During an interview on 8/20/24 at 8:14 AM, Staff B, Clinical Manager identified the DRR is completed by the nurse at admission, recertifications, resumptions of care, with the addition of new medications and at discharge. The DRR is sent to the doctor each time for review. 1.Patient #4 had a start of care date of 7/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 7/18/24 to 9/15/24, included orders for medications. b. A case communication note completed by Staff C, Registered Nurse (RN), identified she completed admission paperwork and a medication review only; skilled nursing was not ordered for patient. The DRR lacked review of ineffective drug therapy, significant side effects, duplicate drug therapy and noncompliance with drug therapy. c. The comprehensive assessment, dated 7/18/24, completed by Staff I, Physical Therapist (PT), lacked documentation a drug regimen review had been completed. The agency failed to complete a drug regimen review with all comprehensive assessments.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency staff interviews and clinical record reviews the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan of Care for 2 of 2 sampled patients with missed visits (Patients #4 and #5). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 2. Patient #5 had a start of care date of 5/17/24. Clinical record review revealed the following: a. The POC, dated 7/16/24 to 9/13/24, included physician orders for skilled nursing services. b. The physician's order, dated 8/1/24, included orders for bath aide 3 times a week. b. The electronic record lacked documentation of home health aide visits the week of 8/4/24 to 8/10/24. The clinical record lacked documentation of physician notification of the 3 missed home health aide visits. The agency failed to notify the physician of missed visits and/or the need to vary visit frequency. The above findings shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, Licensed Practical Nurse (LPN). During an interview on 8/21/24 at 11:30 AM, Staff B, Clinical Manager, identified the agency notifies the physician of all missed visits. 1.Patient #4 had a start of care date of 7/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 7/18/24 to 9/15/24, included physician orders for skilled nursing services two times per week for two weeks effective 7/18/24. b. The week of 7/14/24 to 7/20/24 included documentation of one skilled nursing visit to complete admission paperwork and review medication. The clinical record lacked documentation of physician notification of the missed skilled nursing visit. During an interview on 8/21/24 at 10:00 AM, Staff C, Registered Nurse (RN) revealed skilled nursing services were initially ordered only to complete admission paperwork and review medications and should not have included skilled nursing visits twice a week for two weeks effective 7/18/24. The agency failed to notify the physician of missed visits and/or the need to vary visit frequency.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 patients (Patients #1, #2 and #3) with home visit observations. Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care, dated 5/2023, an individualized plan of care is required for each client receiving home health and personal care services. The plan of care includes but is not limited to the following: medications, treatments and procedures, medical supplies and equipment required, type, frequency and duration of all visits/services, rehabilitation potential, prognosis and special dietary or nutritional requirements. 1.Patient #1 had a start of care date of 1/17/20. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/24/24 to 8/22/24 included an order for the following medication: Calcium-Vitamin D3 with instructions to take 1 tablet by mouth twice daily. The order lacked medication dosage. b. The POC included the following durable medical equipment (DME) used by the patient: CPAP/BiPAP, Oxygen, Incentive Spirometer, Nebulizer, Shower Chair, Walker and Med box. c. During a home visit observation on 8/19/24 at 1:00 PM, with Staff C, Registered Nurse (RN), the surveyor identified the following additional DME in the home: life alert button and glucose monitor. During this same visit, an interview with the patient revealed both devices have been utilized by the patient for greater than a year. The POC failed to identify complete medication orders with dosage and all DME the patient required for use. 2. Patient #2 had a start of care date of 11/20/23. Clinical record review revealed the following: a. The POCs, dated 5/8/24 to 7/16/24 and 7/17/24 to 9/14/24, included an order for the following medications: Acetaminophen milligram (mg)as needed every 6 hours, Vitamin D units twice daily and Baclofen (muscle relaxant) mg twice daily in AM and PM. The orders lacked medication dosage. b. The POC included the following durable medical equipment (DME) used by the patient: CPAP/BiPAP, nebulizer, shower chair, walker, wheelchair cushion, B/P cuff, oximeter, catheter bag purses x 2 and scale. c. During a home visit observation on 8/19/24 at 11:30 AM, with Staff D, RN, the surveyor identified the following additional DME in the home: hand held shower and bed rail. During this same visit, an interview with the patient revealed both devices have been utilized by the patient prior to the start of home health services. The POC failed to identify complete medication orders with dosage and all DME the patient required for use. 3. Patient #3 had a start of care date of 8/16/24. Clinical record review revealed the following: a. The POC, dated 8/16/24 to 10/14/24, included the following DME used by the patient: LVAD (left ventricular device) sterile dressing supplies. b. During a home visit observation on 8/19/24 at 11:30 AM, with Staff B, Clinical Manager, the surveyor identified the following additional DME in the home: wheelchair, walker, scale and a reacher. During this same visit, an interview with the patient revealed all devices have been utilized by the patient prior to the start of home health services. The POC failed to identify all DME including a wheelchair, walker, scale and reacher the patient required for use. The above findings were shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, Licensed Practical Nurse (LPN). According to the agency policy titled Plan of Care, dated 5/2023, an individualized plan of care is required for each client receiving home health and personal care services. The plan of care includes but is not limited to the following: medications, treatments and procedures, medical supplies and equipment required, type, frequency and duration of all visits/services, rehabilitation potential, prognosis and special dietary or nutritional requirements. 1.Patient #1 had a start of care date of 1/17/20. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/24/24 to 8/22/24 included an order for the following medication: Calcium-Vitamin D3 with instructions to take 1 tablet by mouth twice daily. The order lacked medication dosage. b. The POC included the following durable medical equipment (DME) used by the patient: CPAP/BiPAP, Oxygen, Incentive Spirometer, Nebulizer, Shower Chair, Walker and Med box. c. During a home visit observation on 8/19/24 at 1:00 PM, with Staff C, Registered Nurse (RN), the surveyor identified the following additional DME in the home: life alert button and glucose monitor. During this same visit, an interview with the patient revealed both devices have been utilized by the patient for greater than a year. The POC failed to identify complete medication orders with dosage and all DME the patient required for use. 2. Patient #2 had a start of care date of 11/20/23. Clinical record review revealed the following: a. The POCs, dated 5/8/24 to 7/16/24 and 7/17/24 to 9/14/24, included an order for the following medications: Acetaminophen milligram (mg)as needed every 6 hours, Vitamin D units twice daily and Baclofen (muscle relaxant) mg twice daily in AM and PM. The orders lacked medication dosage. b. The POC included the following medical equipment used by the patient: CPAP/BiPAP, nebulizer, shower chair, walker, wheelchair cushion, B/P cuff, oximeter, catheter bag purses x 2 and scale. c. During a home visit observation on 8/19/24 at 11:30 AM, with Staff D, RN, the surveyor identified the following additional medical equipment in the home: hand held shower and bed rail. During this same visit, an interview with the patient revealed both devices have been utilized by the patient prior to the start of home health services. The POC failed to identify complete medication orders with dosage and all DME the patient required for use. 3. Patient #3 had a start of care date of 8/16/24. Clinical record review revealed the following: a. The POC, dated 8/16/24 to 10/14/24, included the following medical equipment used by the patient: LVAD (left ventricular device) sterile dressing supplies. b. During a home visit observation on 8/19/24 at 11:30 AM, with Staff B, Clinical Manager, the surveyor identified the following additional medical equipment in the home: wheelchair, walker, scale and a reacher. During this same visit, an interview with the patient revealed all devices have been utilized by the patient prior to the start of home health services. The POC failed to identify all DME including a wheelchair, walker, scale and reacher the patient required for use. The above findings were shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, Licensed Practical Nurse (LPN).

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, agency policy review and clinical record review, the agency failed to ensure 2 of 4 sampled home health aides (Staff F and G), demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently for 2 patients (Patient #4 and #7). Failure to ensure that home health aides demonstrated completion of all of the assigned extra skills while observed by a registered nurse (RN) to determine competency in each task prior to being allowed to care for agency patients independently, increased the potential risk of harm to the patient. Findings include: According to the agency policy, titled Home Health Aide Care Plan and revised 3/2022, the home health aide shall be oriented by a RN via phone or in person to the client's care needs prior to initiating the care and updated on modifications or changes in the client's care. If the home health aide is assigned to delegated nursing junctions, such ass assisting to administer medications that are normally self-administered, i.e., eye drops; the home health aide must be oriented to the procedure by a RN who documents evidence of competency. 1.Patient #4 had a start of care date of 7/18/24. Clinical record review revealed the following: a. The Plans of Care, dated 7/18/24 to 9/15/24, included physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The home health aide care plan, dated 7/18/24, directed the aide to apply edema wear and apply miconazole powder to skin folds that are red. c. The application of edema wear and medicated topicals require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff F, Home Health Aide, provided care to Patient #4. Personnel file review revealed the following: d. Staff F, Home Health Aide, had a hire date of 1/13/21. Staff F had never been competency tested to perform the application of a medicated topical powder. 2. Patient #7 had a start of care date of 4/8/22 and discharge date of 5/26/24. Clinical record review revealed the following: a. The Plans of Care, dated 1/28/24 to 3/27/24 and 3/28/24 to 5/26/24, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 3/28/24, directed the aide to weight the patient, apply light dusting of nystatin powder and apply lidocaine 4% roll on liquid or patch to affected areas across upper back and shoulder blades. c. The weight, application of medicated topicals and application of medicated patch require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff G, Home Health Aide, provided care to Patient #7. Personnel file review revealed the following: d. Staff G, Home Health Aide, had a hire date of 4/22/22. Staff G had never been competency tested to perform the application of a medicated patch. During an interview on 8/21/24 at 10:10 AM Staff D, RN stated she remembered showing Staff G, home health aide, how to apply the medicated patch. Staff D, RN unable to locate documentation of Staff G's competency testing. The above findings were reviewed with the Administrator and Clinical Manager.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 3 sampled patients receiving home health aide services (Patients #5 and #7). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patients would receive inappropriate or inconsistent home health aide services. Findings include: 2.Patient #7 had a start of care date of 4/8/22, a discharge date of 5/26/24 and received skilled nursing and home health aide services. Clinical record review revealed the following: The home health aide care plan, dated 3/28/24, directed the home health aide to provide foot care every visit and to apply lotion every visit. The home health aide care plan failed to identify what foot care included and where the home health aide was to apply lotion. The above findings shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, Licensed Practical Nurse (LPN). According to the agency policy, titled Home Health Aide Care Plan, revised 3/2022, following the initial nursing assessment and consultation with the clint/caregiver, written instructions for home care are prepared by a RN or therapist, as appropriate. The care plan shall be developed in plain, non-technical lay terms and identify the duties to be performed such as, but not limited to: personal care, ambulation and exercise, household services essential to health care at home, assistance with treatments, medications and procedures as needed and per State/Federal standards and conditions of participation and meal planning and preparation when supportive of health maintenance and promotion. 1. Patient #5 had a start of date of 5/17/24. Clinical record review revealed: a. The Plan of care, dated 7/16/24 to 9/13/24, included orders for skilled nursing services. b. The physician's order, dated 8/1/24, included orders for a bath aide 3 times a week. c. Review of the clinical record, dated 8/12, 8/14 and 8/16/24, included documentation aide services provided to the patient. d. The clinical record lacked documentation of a written home health aide care plan. e. During an interview on 8/20/24 at 2:45 PM the Clinical Manager stated she failed to complete a home health aide care plan but did give verbal instruction to the aide for services provided. The agency failed to provide written instruction for the aide assignment.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency interviews, clinical record reviews and agency policy reviews, the agency failed to ensure home health aides provided care to patients only as ordered by a physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 3 sampled patients receiving home health aide services (Patients #5 and #7). Failure to ensure home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the plan of care increased the risk that the patient's personal care needs were not adequately met. Findings include: 2. Patient #5 had a start of date of 5/17/24. Clinical record review revealed: a. The Plan of care, dated 7/16/24 to 9/13/24, included orders for skilled nursing services. b. The physician's order, dated 8/1/24, included orders for a bath aide 3 times a week. c. Review of the clinical record, dated 8/12, 8/14 and 8/16/24, included documentation aide services provided to the patient. The documentation failed to include what tasks completed by the home health aide. d. The clinical record lacked documentation of a written home health aide care plan. e. During an interview on 8/20/24 at 2:45 PM the Clinical Manager stated she failed to complete a home health aide care plan but did give verbal instruction to the aide for services provided. The aide unable to document due to no care plan available. The agency failed to include documentation of tasks provided during aide services. The above findings shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, Licensed Practical Nurse (LPN). According to the agency policy titled Home Health Aide Care Plan, dated 5/2023, a Registered Nurse (RN) or Therapist completes and appropriate care plan identifying the duties to be performed by the Home Health Aide. The home health aide cannot be responsible for doing any procedure that is not assigned to him/her in writing by the RN. During an interview on 8/20/24 at 8:14 AM, Staff B, Clinical Manager, identified when a patient requests a home health aide to complete an unassigned task, the home health aide should contact the Clinical Manager. 1.Patient #7 had a start of care date of 4/8/22 and a discharge date of 5/26/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 3/28/24 to 5/26/24, included physician orders for skilled nursing services twice monthly and home health aide visits twice weekly to assist with personal cares. b. The home health aide care plan, dated 3/28/24 to 5/26/24, identified the following interventions: weight once a week, shower every visit, skin care-apply lotion and foot care. c. Home health aide visit notes for weeks of 3/31/24 to 4/6/24, 4/14/24 to 4/20/24 and 4/21/24 to 4/27/24 failed to include documentation the home health aide performed the task of weighing the patient one time a week and failed to document why the task was not performed. d. Home health aide visit notes dated 4/5/24, 4/12/24 and 4/26/24 identified the home health aide performed a sponge bath instead of a shower per patient request. The home care aide failed to notify the Clinical Manager and/or RN regarding completion of a task not assigned on the patient's POC. The home health aide failed to provide services ordered by the physician and included in the patient's POC.

Basis and Scope CFR(s): §484.80(h)(1)(iv) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This STANDARD is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure a registered nurse or other appropriate professional completed an annual on-site visit to observe and assess each aide while the home health aide present and providing direct patient care (Staff F and G). Failure to supervise home health aide services, at least annually while the aides provided direct patient care, increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency policy titled Home Health Aide Supervision, dated November, 2019, when skilled nursing care is being furnished to a client, a RN must make a supervisory visit to the client's residence at least every 2 weeks to assess relationships and determine whether goals are being met. If home health aide services are provided to a patient who is not receiving skilled nursing care, physical therapy or occupational therapy or speech-language pathology services, the RN must make a supervisory visit to the patient's home no less frequently than every 60 days for each aide providing routine care. In these cases, to ensure that the aide is properly caring for the patient, each supervisory visit must occur while the home health aide is providing patient care. 1. Staff F, Home Health Aide (HHA) had a hire date of 1/13/21. Review of Staff F's employee file lacked documentation of annual direct supervision by an RN or other appropriate professional. The agency failed to provide annual on-site visit to observe and assess each aide while the HHA provided direct patient care. 2. Staff G, HHA had a hire date of 4/22/22. Review of Staff G's employee file lacked documentation of annual direct supervision by an RN or other appropriate professional. The agency failed to provide annual on-site visit to observe and assess each aide while the HHA provided direct patient care. The above findings were reviewed with the Administrator and Clinical Manager.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on agency interviews, clinical record reviews and agency policy reviews, the home health agency failed to ensure all clinical documentation was completed in a timely manner for 4 of 7 sampled patients (Patients #1, #4, #6 and #7). Failure to ensure all clinical record documentation was completed in a timely manner increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the agency policy titled Home Health Documentation, dated 5/2023, all clinical documentation is to be completed, signed and marked permanent by midnight of the 3rd business day following a visit. During an interview on 8/20/24 at 8:14 AM, the Clinical Manager confirmed routine visit documentation is to be completed within 3 days. 1.Patient #1 had a start of care date of 1/17/20. Clinical record review revealed the following: a. The skilled nurse visit note, dated 6/28/24, signed completed 7/5/24 (2 days late). b. The skilled nurse visit note, dated 7/9/24, signed completed 7/15/24 (1 day late). c. The skilled nurse visit note, dated 7/23/24, signed completed 8/16/24 (15 days late). d. The skilled nurse visit note, dated 8/2/24, signed completed 8/16/24 (7 days late). e. The skilled nurse visit note, dated 8/6/24, signed completed 8/12/24 (1 day late). The agency clinical record failed to include timely documentation. 2.Patient #4 had a start of care date of 7/18/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 7/23/24, signed completed 8/12/24 (11 days late). b. The skilled nurse visit note, dated 7/30/24, signed completed 8/8/24 (4 days late). c. The skilled nurse visit note, dated 8/2/24, signed completed 8/14/24 (5 days late). The agency clinical record failed to include timely documentation. 3.Patient #6 had a start of care date of 9/9/23 and a discharge date of 7/24/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 6/11/24, signed completed 6/25/24 (7 days late). b. The skilled nurse visit note, dated 6/18/24, signed completed 6/25/24 (2 days late). c. The skilled nurse visit note, dated 7/2/24, signed completed 7/9/24 (2 days late). d. The skilled nurse visit note, dated 7/16/24, signed completed 7/31/24 (8 days late). The agency clinical record failed to include timely documentation. 4.Patient #7 had a start of care date of 4/8/22 and a discharge date of 5/26/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 4/9/24, signed completed 4/18/24 (4 days late). b. The skilled nurse visit note, dated 4/17/24, signed completed 4/25/24 (3 days late). c. The skilled nurse visit note, dated 4/24/24, signed completed 5/6/24 (5 days late). d. The skilled nurse visit note, dated 5/8/24, signed completed 5/20/24 (5 days late). The agency clinical record failed to include timely documentation. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff F, LPN.

The combined COVID-19 Focused Infection Control Survey and recertification survey conducted from 10/4/2021 to 10/6/2021, found the agency operating in substantial compliance with the COVID-19 requirements for emergency preparedness and pandemic illnesses. The recertification survey identified the following standard level deficient practices related to the Establishment of Emergency Preparedness requirements.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency's emergency preparedness policies and agency staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty directly hired staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The agency reported a current census of 27 patients and employed 10 home health directly hired staff at the time of the survey. Failure to have procedures in place for to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's emergency preparedness plan and policies revealed a lack of policy identifying the procedures the agency will take if unable to locate any patient or on duty directly hired staff. During agency staff interview on 10/6/21 at 12:00 PM, the surveyor reviewed the findings with the Clinical Manager. The Clinical Manager looked through the policies and also was unable to locate the required policy. The agency provided no additional information prior to the end of the survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in the agency's emergency preparedness policies and procedures at hire and every 2 years thereafter for 4 of 5 sampled directly hired staff and for 7 of 7 sampled contracted staff consistent with their expected roles in the event of an emergency/disaster. The agency reported employing 10 staff directly and 44 therapy and home health aide staff by contract at the time of the survey. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: The agency emergency preparedness book lacked the following: 1. Staff C, Registered Nurse (RN), directly hired on 11/3/2014- training completed on 11/5/2018. No other documentation of training. 2. Staff F, Licensed Practical Nurse (LPN), directly hired on 2/28/2011- training completed on 11/5/2018. No other documentation of training. 3. Staff K, Administrative Assistant, directly hired on 2/6/2017- No documentation of training. 4. Staff L, Clerical Support, directly hired 10/1/2020- No documentation of training. 5. Staff M, Home Health Aide (HHA), contracted 1/12/2009- training completed 11/8/2018- No other documentation of training. 6. Staff H, HHA, contracted 1/10/2019- No documentation of training. 7. Staff I, HHA, contracted 8/2/2021- No documentation of training. 8. Staff E, Physical Therapy Assistant (PTA), contracted 7/27/2021- No documentation of training. 9. Staff N, Physical Therapist (PT), contracted 10/7/2018- training completed 10/7/2018 and 2/23/2019- No other documentation of training. 10. Staff O, PTA, contracted 4/14/2020- No documentation of training. 11. Staff P, Occupational Therapist (OT), contracted 6/10/2021- No documentation of training. During agency staff interview on 10/6/2021 at 1:35 PM, the Clinical Manager reported she had not had any contracted staff review the home health agency's emergency preparedness plan or policies. She reported verbally reviewing pieces of the emergency plan/policies with directly hired staff but did not document the reviews. The agency provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 10/4/2021 through 10/6/2021 . The survey found the agency to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements:

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to complete drug regimen reviews within the regulatory timing guidelines at the time of start of care and recertification for 4 of 8 sampled patients (Patients #1, #4, #5 and #6). The agency reported a census of 27 patients at the time of the survey. Failure to ensure medications were reviewed at the time of each comprehensive assessment, using a current and accurate list of medications taken by the patient at the time of the assessment, increased the potential for unidentified medication interactions, patient non-compliance, ineffective medication therapy and side effect risks to the patient. Findings include: According to the agency policy, titled Comprehensive Assessment and dated 1/2021, all medications will be reviewed at the time of each comprehensive assessment 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. The initial comprehensive assessment at start of care must be completed within 5 days following the start of care. The update to the comprehensive assessment at recertification must be completed between day 56 and 60 of each 60 day certification period. During agency staff interview on 10/4/2021 at 11:45 AM, the Clinical Manager reported the registered nurses perform a drug regimen review at start of care, recertification, resumption of care following hospitalization, with significant changes in patient condition and upon discharge from home health services by reviewing all medications taken by the patient. The drug regimen review is documented on the patient's Plan of Care and sent to the physician for notification of any concerns identified during the review. 1. Patient #1 had a start of care date of 8/27/2021 and received skilled nursing and physical therapy services. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 8/27/2021, documented the patient's start of care date as 8/27/2021. The assessment was initiated with a home visit on 8/27/2021 and completed on 9/1/2021. b.. The Plan of Care, dated 8/27/2021 to 10/25/2021, documented the patient's start of care date as 8/27/2021. The Plan of Care included documentation of a drug regimen review, dated as completed on 8/25/2021, 2 days before the agency admitted the patient. c. The clinical record lacked documentation of any drug regimen review completed between 8/27/2021 and 9/1/2021 (the fifth day following start of care). The nurse completed the drug regimen review prior to visiting the patient's home to obtain an accurate list of medications taken by the patient. 2. Patient #4 had a start of care date of 11/21/2018 and received personal care only services provided by a home health aide without provision of any skilled service. Clinical record review revealed the following: a. The Plans of Care, dated 3/10/2021 to 5/8/2021; 5/9/2021 to 7/7/2021; 7/8/2021 to 9/5/2021 and 9/6/2021 to 11/4/2021, included physician orders for the registered nurse to visit the patient once every 60 days to supervise the home health aide and complete a comprehensive assessment for recertification. b. The update to the comprehensive assessment at the time of recertification, dated 5/5/2021, was initiated with a home visit on 5/5/2021 and completed on 5/6/2021. The Plan of Care, dated 5/9/2021 to 7/7/2021, included documentation of a drug regimen review, dated as completed on 5/3/2021, 2 days before the nurse visited the patient to complete the comprehensive assessment and update the patient's Plan of Care. The clinical record lacked documentation of any drug regimen review completed between 5/4/2021 to 5/8/2021 (day 56 to 60 of the previous certification period). The nurse completed the drug regimen review prior to visiting the patient's home to obtain an accurate list of medications taken by the patient. c. The update to the comprehensive assessment at the time of recertification, dated 7/6/2021, was initiated with a home visit on 7/6/2021 and completed on 7/7/2021. The Plan of Care, dated 7/8/2021 to 9/5/2021, included documentation of a drug regimen review, dated as completed on 7/5/2021, 1 day before the nurse visited the patient to complete the comprehensive assessment and update the patient's Plan of Care. The nurse completed the drug regimen review prior to visiting the patient's home to obtain an accurate list of medications taken by the patient. 3. Patient #5 had a start of care date of 9/5/2021 and received skilled nursing services. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 9/5/2021, documented the patient's start of care date as 9/5/2021. The assessment was initiated with a home visit on 9/5/2021 and completed on 9/12/2021. b.. The Plan of Care, dated 9/5/2021 to 11/3/2021, documented the patient's start of care date as 9/5/2021. The Plan of Care included documentation of a drug regimen review, dated as completed on 9/4/2021, 1 day before the agency admitted the patient. c. The clinical record lacked documentation of any drug regimen review completed between 9/5/2021 and 9/10/2021 (the fifth day following start of care). The nurse completed the drug regimen review prior to visiting the patient's home to obtain an accurate list of medications taken by the patient. 4. Patient #6 had a start of care date of 6/4/2021 and received skilled nursing services. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 6/4/2021, documented the patient's start of care date as 6/4/2021. The assessment was initiated with a home visit on 6/4/2021 and completed on 6/18/2021. b.. The Plan of Care, dated 6/4/2021 to 8/2/2021, documented the patient's start of care date as 6/4/2021. The Plan of Care included documentation of a drug regimen review, dated as completed on 6/3/2021, 1 day before the agency admitted the patient. c. The clinical record lacked documentation of any drug regimen review completed between 6/4/2021 and 6/9/2021 (the fifth day following start of care). The nurse completed the drug regimen review prior to visiting the patient's home to obtain an accurate list of medications taken by the patient. The above stated findings for Patients #1, #4, #5 and #6 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review, agency staff interview and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments with accompanying drug regimen review between day 56 and 60 of each 60 day certification period for 2 of 4 sampled patients requiring an update to the comprehensive assessment at the time of recertification (Patients #3 and #4). The agency reported a census of 27 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessment and updated 1/2021, agency clinicians must complete documentation of the update to the comprehensive assessment at the time of recertification in the last 5 days of each 60 day certification period (day 56 to 60). A drug regimen review will accompany each comprehensive assessment at start of care, recertification, resumption of care, significant change in condition and discharge. During agency staff interview on 10/4/2021 at 11:45 AM, the Clinical Manager reported the registered nurses perform a drug regimen review at start of care, recertification, resumption of care following hospitalization, with significant changes in patient condition and upon discharge from home health services by reviewing all medications taken by the patient. The drug regimen review is documented on the patient's Plan of Care and sent to the physician for notification of any concerns identified during the review. 1. Patient #3 had a start of care date of 3/26/2021 and received skilled nursing, physical therapy and home health aide services. Clinical record revealed the following: a. The Plans of Care, dated 3/26/2021 to 5/24/2021 and 5/25/2021 to 7/23/2021, included physician orders for skilled nursing, physical therapy and home health aide services. The Plan of Care, dated 5/25/2021 to 7/23/2021, included documentation of a drug regimen review dated as completed on 5/26/2021 (the second day of the new certification period, making the review 2 days late. The patient's clinical record included an update to the comprehensive assessment at the time of recertification, dated as begun on 5/20/2021 (day 56 of the current certification period). The assessment was electronically signed as complete on 5/29/2021, the fifth day of the upcoming certification period, making the assessment five days late. b. The Plans of Care, dated 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, included physician orders for skilled nursing, physical therapy and home health aide services. The patient's clinical record included an update to the comprehensive assessment at the time of recertification, dated as begun on 9/21/2021 (day 60 of the current certification period). The assessment was electronically signed as complete on 9/23/2021, the second day of the upcoming certification period, making the assessment two days late. 2. Patient #4 had a start of care date of 11/21/2018 and received home health aide services without a skilled services. Clinical record revealed the following: The Plans of Care, dated 7/8/2021 to 9/5/2021 and 9/6/2021 to 11/4/021, included physician orders for skilled nursing every 60 days to supervise the aide and complete a recertification comprehensive assessment. The patient's clinical record included an update to the comprehensive assessment at the time of recertification, dated as begun on 9/1/2021 (day 56 of the current certification period). The assessment was electronically signed as complete on 9/6/2021, the first day of the upcoming certification period, making the assessment one day late. The above stated findings for Patients #3 and #4 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure completion of the update to the comprehensive assessment with accompanying drug regimen review within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #3). The agency provided services to 27 patients at the time of the survey and performed 4 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessments and updated in 1/2021, an update to the comprehensive assessment for resumption of care following a hospital inpatient admission will be completed within 48 hours of the patient's return home from the facility, within 48 hours of the agency's knowledge of the patient's return home from an inpatient admission or on the physician ordered resumption of care date. Patient #3 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The patient was hospitalized on 4/28/2021 and returned home on 5/15/2021. b. The fax communication note, dated 5/15/2021, documented the patient was discharged from the hospital and the agency could resume services. c. The nurse initiated the update to the assessment on 5/17/2021 but did not complete the assessment until 5/19/2021, 4 days after the agency received knowledge the patient had returned home from the inpatient stay. The assessment was completed 2 days late as required by regulation and the agency's own policy. The surveyor reviewed the above stated findings for Patient #3 with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on agency policy review, agency staff interview and clinical record review, the agency failed to ensure completion of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 1 of 1 sampled patients requiring a discharge comprehensive assessment (Patient #7). The agency reported a census of 27 patients at the time of the survey and performed discharge assessments on 17 patients between 4/1/2021 and 6/30/2021. Failure to accurately and thoroughly complete discharge comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessment and updated 1/2021, agency clinicians must complete documentation of the update to the comprehensive assessment at the time of discharge within 2 days of the identification of the need to discharge. A drug regimen review will accompany each comprehensive assessment at start of care, recertification, resumption of care, significant change in condition and discharge. During agency staff interview on 10/4/2021 at 11:45 AM, the Clinical Manager reported the registered nurses perform a drug regimen review at start of care, recertification, resumption of care following hospitalization, with significant changes in patient condition and upon discharge from home health services by reviewing all medications taken by the patient. The drug regimen review is documented on the patient's Plan of Care and sent to the physician for notification of any concerns identified during the review. During agency staff interview on 10/4/2021 at 12:40 PM, the Clinical Manager reported she was still working on the drug regimen review for Patient #7 to close out the clinical record. The Clinical Manager reported the patient was discharged last week and believed she had 2 business days to complete the drug regimen review. Patient #7, a pediatric patient receiving therapy only services, had a start of care date of 4/6/2021 and was discharged from agency services on 10/1/2021. Clinical record revealed the following: a. The Plan of Care, dated 8/4/2021 to 10/2/2021, included physician orders for physical therapy services 1-2 times weekly. b. The update to the comprehensive assessment at the time of discharge, was completed by the physical therapist on 10/1/2021. c. The discharge summary, dated 10/4/2021, documented the patient's discharge date as 10/1/2021. The note included documentation of a drug regimen review to accompany the discharge assessment; however, the review was completed on 10/4/2021, 3 days after the patient was discharged. The above stated findings for Patient #7 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, agency staff interview and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate medication/treatment orders for 3 of 8 sampled patients (Patients #2, #3 and #5). The agency reported a current census of 27 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 1. Patient #2 had a start of care date of 9/16/2021. Clinical record review, surveyor observation and patient interview revealed: a. The Plan of Care, dated 9/16/2021 to 11/14/2021, documented Patient #2's diagnoses as recent hip fracture, rheumatoid arthritis and history of falls. b. During the home visit observation on 10/5/2021 at 9:45 AM while accompanied by Staff D, Registered Nurse (RN), the surveyor observed a heating pad in the patient's home. c. Patient interview during the home visit revealed the patient had used of heating pad for the past 45 years for pain relief associated with rheumatoid arthritis. d. The Plan of Care listed above did not include the heating pad as equipment used by the patient to meet his/her individualized needs. 2. Patient #3 had a start of care date of 3/26/2021. Clinical record review, surveyor observation and patient interview revealed: a. The Plans of Care, dated 3/26/2021 to 5/24/2021; 5/25/2021 to 7/23/2021; 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, documented Patient #3's diagnoses as chronic kidney disease with heart failure; osteoarthritis; pulmonary hypertension and atrial fibrillation. b. During the home visit observation on 10/5/2021 at 1:00 PM while accompanied by Staff E, Physical Therapy Assistant (PTA), the surveyor observed a portable automatic blood pressure machine setting on the end table next to the patient's lift chair. The patient used the lift chair multiple times during the home visit when working with the therapist on home exercises. The surveyor observed the patient wore braces on both ankles. c. Patient interview during the home visit revealed the patient uses the blood pressure machine independently to monitor when having symptoms of hypertension or when dosage of antihypertensive is made. The patient reported the inability to stand/walk without weakness, requiring the use of the lift chair to assist with standing. The patient reported he/she wears bilateral ankle braces due to a past history of fracture requiring multiple surgeries on one ankle and a history of deep sprain on the other. Both ankles are reportedly weak and turn easily. The braces are used to support both ankles when walking. d. The Plans of Care listed above did not include the automatic blood pressure machine, lift chair or ankle braces as equipment used by the patient to meet his/her individualized needs. e. The Plan of Care, dated 9/22/2021 to 11/20/2021, included duplicate medication orders for the same medication. The medication was listed as the generic name, polyethylene glycol and also listed as the manufacturers trade name Miralax. Both medication names were listed as separate orders. 3. Patient #5 had a start of care date of 9/5/2021. Clinical record review and agency staff interview revealed: a. The Plan of Care, dated 9/5/2021 to 11/3/2021, documented Patient #5's diagnoses as congestive heart failure with pleural effusion requiring the current use of a drain to remove fluid from the space around the lungs. b. The communication note, dated 9/28/2021, documented the results of a halter monitor (a portable electrocardiogram) worn by the patient at home to monitor the electrical activity of the heart continuously. c. The Plan of Care listed above did not include the halter monitor as equipment used by the patient to meet his/her individualized needs. d. During agency staff interview on 10/6/2021 at 10:55 AM, the Clinical Manager reported Patient #5 wore the halter monitor for 3 days after start of care. She concurred the halter monitor should have been placed on the Plan of Care initially as the patient used the monitor to meet his/her needs. The above stated findings for Patients #2, #3 and #5 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of #2, #3, #5 and #6) The agency reported a current census of 27 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: During agency staff interview on 10/4/2021 at 2:00 PM, the Clinical Manager reported she went to a training the previous week and learned of the need to have all verbal/interim orders added to a working Plan of Care update for all staff to work from. The Clinical Manager reported she came back and started working on a plan to update all of the patient's Plans of Care. 1. Patient #1 had a start of care date of 8/27/2021. Clinical record review and agency staff interview revealed the following: a. The Plan of Care, dated 8/27/2021 to 10/25/2021, included orders for skilled nursing visits 1-2 times weekly for 4 weeks. The clinical record included a physician's interim order, dated 9/19/2021, skilled nursing visits 1-2 times for an additional 5 weeks. After Patient #1 was chosen as part of the survey sample, the Clinical Manager printed and provided the surveyor with an updated Plan of Care that did include the above stated physician orders. The Plan of Care was not electronically signed or dated. During agency staff interview on 10/4/2021 at 2:00 PM, the Clinical Manager reported she had updated the Plan of Care earlier after the surveyor requested review of Patient #1's clinical record. b. The clinical record included a physician's interim order, dated 9/27/2021, ordering omeprazole 40 milligrams (mg) daily. The same interim order directed the skilled nurse to begin setting up the patient's medications from dispensed envelopes and assess for compliance with the medication regimen. The Plan of Care, dated 8/27/2021 to 10/25/2021, lacked orders for the nurse to set up the patient's medications and lacked inclusion of omeprazole as a medication taken by the patient. After Patient #1 was chosen as part of the survey sample, the Clinical Manager printed and provided the surveyor with an updated Plan of Care that did include the above stated physician orders. The Plan of Care was not electronically signed or dated. During agency staff interview on 10/4/2021 at 2:00 PM, the Clinical Manager reported she had updated the Plan of Care earlier after the surveyor requested review of Patient #1's clinical record. 2. Patient #2 had a start of care date of 9/16/2021. Clinical record review revealed the following: The Plan of Care, dated 9/16/2021 to 11/14/2021, included physician orders for Coumadin 8 mg daily. The patient's medication list, dated 9/27/2021, documented the patient took Coumadin 8 mg every other day; alternating with 9 mg on the opposite days. The patient's clinical record included a communication note, dated 9/27/2021, documenting communication with the patient's physician who changed the dose of the Coumadin as described in the medication list. As of review of the clinical record on 10/4/2021 at 3:00 PM, the clinical record lacked the transcribed verbal order or addition of a Plan of Care update reflecting the change. 3. Patient #3 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The interim physician order, dated 9/10/2021, added Cefdinir 300 mg twice daily to the patient's medication regimen for 10 days. The Plan of Care, dated 7/24/2021 to 9/21/2021, did not include the medication Cefdinir. The verbal order was not added to a Plan of Care update. b. The interim physician order, dated 9/3/2021, ordered the nurse to apply a small piece of wicking fiber dressing to the patient's bunion on the right foot and cover with a bunion pad, changing both 1-2 times per week. The Plan of Care, dated 7/24/2021 to 9/21/2021, did not include the wound care order. The verbal order was not added to a Plan of Care update. c. The interim physician order, dated 9/10/2021, ordered the nurse to apply calmoseptine to the right great toe open area and cover with wicking fiber then Band-Aid to secure, changing 1-2 times weekly. The Plan of Care, dated 7/24/2021 to 9/21/2021, did not include the wound care order. The verbal order was added to a Plan of Care update on 10/4/2021 by the Clinical Manager after the patient was chosen as part of the survey sample. 4. Patient #5 had a start of care date of 9/5/2021. Clinical record review revealed the following: The Plan of Care, dated 9/5/2021 to 11/3/2021, included orders to drain the patient's PleurX catheter (a drain tube placed in the patient's chest wall to drain fluid from the pleural space around the lungs) every other day. The interim physician's order, dated 9/16/2021, modified the original order to drain the patient's Pleurx drain every other day to include "Once less than 75 milliters of fluid was drained consecutively 3 times, contact the clinic to schedule removal of the drain". The verbal order was not placed onto a Plan of Care update until 10/4/2021 after Patient #5 was chosen as part of the survey sample. 5. Patient #6 had a start of care date of 6/4/2021. Clinical record review revealed the following: a. The interim physician's order, dated 6/23/2021, added Vitamin C with Rose Hips 500 mg daily to the patient's medication regimen. The Plan of Care, dated 6/4/2021 to 8/2/2021, lacked inclusion of the medication. The interim order was not added to a Plan of Care update. b. The Plan of Care, dated 6/4/2021 to 8/2/2021, included orders for Basaglar Kwik Pen insulin 10 units daily. The interim physician's order, dated 7/9/2021, discontinued the Basaglar insulin from the patient's medication regimen. The interim physician's order, dated 8/19/2021, added the Basaglar insulin 10 units daily back into the patient's medication regimen. The interim orders were not added to a Plan of Care update. c. The interim physician order, dated 9/13/2021, directed the nurse to complete routine monthly testing for CBC (Complete Blood Count). The Plan of Care, dated 8/3/2021 to 10/1/2021, did not include routine CBC testing orders. The interim order was not placed onto a Plan of Care update. The above stated findings for Patients #1, #2, #3, #5 and #6 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency skilled professionals failed to follow the physician ordered Plan of Care for 2 of 7 sampled patients receiving a skilled service (Patients #1 and #6). The agency reported a current census of 27 patients, including 23 who received skilled services. Failure to ensure that skilled professionals provided care only as ordered by the physician increased the risk that patients' health care needs would not be adequately met in a safe manner. Findings include: 1. Patient #1 had a start of care date of 8/27/2021. Clinical record review revealed the following: The Plan of Care, dated 8/27/2021 to 10/25/2021, documented Patient #1's diagnoses as Covid 19 infection resulting in pneumonia; metabolic encephalopathy; hypothyroidism and history of falls. The Plan included physician orders for skilled nursing visits 1-2 times per week. The Plan of Care included direction to the nurse to monitor patient's weight loss and nutrition status. The initial comprehensive assessment at the time of start of care, dated 8/27/2021, documented the patient weighed 150.2 pounds. a. The skilled nurse visit note, dated 8/31/2021, documented the nurse's inability to weigh the patient as the batteries in the scale were dead. The skilled nurse visit note, dated 9/3/2021, later that week documented the nurse weighed the patient and the patient weighed 154 pounds. b. The skilled nurse visit note, dated 9/9/2021, documented the nurse's inability to weigh the patient as the scale was not in working order. No other skilled nurse visits were completed during the week of service. c. The skilled nurse visit note, dated 9/16/2021, lacked documentation of the patient's weight or documentation of the reason for omission of the task. No other skilled nurse visits were completed during the week of services. d. The skilled nurse visit note, dated 9/23/2021, documented the nurse's inability to weigh the patient as the batteries in the scale were dead. No other skilled nurse visits were completed during the week of service. e. The skilled nurse visit note, dated 9/28/2021, documented the patient weighed 157 pounds. The surveyor reviewed the above stated findings with the Clinical Manager. During agency staff interview on 10/6/2021 at 1:15 PM, the Clinical Manager reported each nurse carries a scale and the agency has extra batteries available to the nurses for the scales. "I am unsure why they didn't address and check the weights." The agency provided no additional information prior to the end of the survey. 2. Patient #6 had a start of care date of 6/4/2021. Clinical record review revealed the following: The Plans of Care, dated 6/4/2021 to 8/2/2021 and 8/3/2021 to 10/1/2021, documented Patient #6's diagnoses as combined systolic and diastolic heart failure and diabetes. The Plan included physician orders for skilled nursing visits 1-2 times per week. The Plan of Care included direction to the nurse to monitor patient's weight gain, reporting a gain of 2-3 pounds in 1 day or 5 pounds in 1 week. The nurse was also to monitor the patient's blood glucose readings, reporting any readings less than 70 twice in a row or readings over 240 with symptoms of illness. a. The skilled nurse visit note, dated 6/7/2021, documented the nurse visited with the patient about "low blood sugars" but did not documented a range, a reading during the visit or any communication with the physician. b. The skilled nurse visit note, dated 6/15/2021, lacked any documentation indicating the nurse assessed the patient's blood sugars. The note also lacked documentation indicating the nurse weighed the patient during the visit as ordered by the physician. c. The skilled nurse visit note, dated 7/1/2021, lacked any documentation indicating the nurse assessed the patient's blood sugars. The above stated findings were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, agency policy review and clinical record review, the agency failed to ensure 4 of 5 sampled home health aides (Staff G, H, I and J), demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently for 2 patients (Patient #3 and #8). The agency reported a current census of 27, including 13 patients who received home health aide services at the time of the survey. The agency employed 8 home health aides at the time of the survey. Failure to ensure that home health aides demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently, increased the potential risk of harm to the patient. Findings include: According to the agency policy, titled Home Health Aide Care Plan and updated 1/2021, if a home health aide is assigned to delegated nursing functions, the home health aide must orient to the procedure with a registered nurse who documents evidence of competency. 1. Patient #3 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The Plans of Care, dated 3/26/2021 to 5/24/2021, 5/25/2021 to 7/23/2021, 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, included physician orders for skilled nursing, physical therapy and home health aide services. b. The home health aide assignment directed the aide to apply compression stockings to both lower legs, apply a brace to the patient's right ankle, apply Nystatin antifungal powder to the patient's groin/abdominal area when red and apply Band-Aid to cover the patient's bunion on the left great toe area. c. The application of compression stockings, braces, medicated topicals and simple dressing changes require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff G, H, I and J, Home Health Aides, provided care to Patient #3. Personnel file review revealed the following: d. Staff G, Home Health Aide, had a hire date of 12/2/2020 and employment terminated on 9/30/2021. Staff G had never been competency tested to perform the application of braces, application of a medicated topical powder or perform simple dressing changes. e. Staff H, Home Health Aide, had a hire date of 1/22/2019. Staff H had never been competency tested to perform the application of compression stockings, application of braces, application of a medicated topical powder or perform simple dressing changes. f. Staff I, Home Health Aide, had a hire date of 8/11/2021. Staff I had never been competency tested to perform the application of braces, application of a medicated topical powder or perform simple dressing changes. g. Staff J, Home Health Aide, had a hire date of 1/21/2021. Staff J had never been competency tested to perform the application of braces, application of a medicated topical powder or perform simple dressing changes. 2. Patient #8 had a start of care date of 6/8/2021 and was discharged from agency services on 8/6/2021. Clinical record review revealed the following: a. The Plans of Care, dated 6/8/2021 to 8/6/2021, included physician orders for skilled nursing, physical therapy and home health aide services. b. The home health aide assignment directed the aide to shave the patient every home visit. c. Shaving a patient requires extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. The clinical record documented Staff H, Home Health Aide, provided care to Patient #8. Personnel file review revealed the following: d. Staff H, Home Health Aide, had a hire date of 1/22/2019. Staff H had never been competency tested to perform shaving a patient. The above stated findings for Patients #3 and #8 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, the agency failed to ensure home health aides provided care to agency patients as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 4 sampled patients receiving home health aide services (Patients #3 and #8). The agency reported a current census of 27 patients at the time of the survey, including 13 who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: 1. Patient #3 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The Plans of Care, dated 3/26/2021 to 5/24/2021, 5/25/2021 to 7/23/2021, 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, included physician orders for skilled nursing, physical therapy and home health aide services. b. The home health aide assignment directed the aide to apply compression stockings to both lower legs, apply a brace to the patient's right ankle, apply Nystatin antifungal powder to the patient's groin/abdominal area when red and apply Band-Aid to cover the patient's bunion on the left great toe area. c. The application of compression stockings, braces, medicated topicals and simple dressing changes were assigned as an extension of nursing services, requiring the physician to approve the delegation. d. The Plans of Care, dated 3/26/2021 to 5/24/2021, 5/25/2021 to 7/23/2021, 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, lacked documentation of the tasks of compression stocking application, brace application, simple dressing change and the application of the medicated powder as interventions for the aide. e. The clinical record lacked any documentation of physician approval allowing the aide to perform the tasks as an extension of nursing services. Staff G, H, I and J, all home health aides routinely provided all of the above stated tasks when caring for Patient #3. 2. Patient #8 had a start of care date of 6/8/2021 and was discharged from agency services on 8/6/2021. Clinical record review revealed the following: a. The Plans of Care, dated 6/8/2021 to 8/6/2021, included physician orders for skilled nursing, physical therapy and home health aide services. b. The home health aide assignment directed the aide to shave the patient every home visit. Shaving a patient requires physician approval to approve the delegation of the task. c. The Plan of Care, dated 6/8/2021 to 8/6/2021, lacked documentation of the task shave the patient an intervention for the aide. d. The clinical record lacked any documentation of physician approval allowing the aide to perform the task as an extension of nursing services. The clinical record documented Staff H, Home Health Aide, routinely shaved Patient #8 during home health visits. The above stated findings for Patients #3 and #8 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to ensure agency staff completed documentation in a timely manner and according to the agency policy for 5 of 8 sampled patients (Patients #1, #3, #5, #6 and #8). At the time of the survey, the agency reported a current census of 27 patients. Failure of the agency to ensure the clinical record included timely, up-to-date documentation placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: According to the agency policy, titled Home Health Documentation and updated 1/2021, entries into patient records shall be made by authorized personnel only; shall be kept up to date from intake through close of the case; and be completed, signed and dated by the person who provided services. All clinical routine visit documentation must be completed, signed and marked permanent by midnight of the 2nd business day following the visit. During agency staff interview on 10/4/2021 at 2:15 PM, the Clinical Manager reported all staff 2 business days following the day of routine visits to get the documentation complete in the agency's electronic clinical record system. 1. Patient #1 had a start of care date of 8/27/2021. The Plan of Care, dated 8/27/2021 to 10/25/2021, included orders for skilled nursing and physical therapy services. Clinical record review revealed the following: a. The skilled nurse visit note, dated 9/3/2021, was not completed in the agency's electronic system until 9/9/2021, 4 business days (6 calendar days) following the visit, making the documentation 2 days late according to agency policy. b. The skilled nurse visit note, dated 9/16/2021, was not completed in the agency's electronic system until 9/23/2021, 5 business days (7 calendar days) following the visit, making the documentation 3 days late according to agency policy. 2. Patient #3 had a start of care date of 3/26/2021. The Plans of Care, dated 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, included orders for skilled nursing, home health aide and physical therapy services. Clinical record review revealed the following: a. The skilled nurse visit note, dated 7/27/2021, was not completed in the agency's electronic system until 7/30/2021, 3 business days (3 calendar days) following the visit, making the documentation 1 day late according to agency policy. b. The skilled nurse visit note, dated 8/3/2021, was not completed in the agency's electronic system until 8/12/2021, 7 business days (9 calendar days) following the visit, making the documentation 5 days late according to agency policy. c. The skilled nurse visit note, dated 9/14/2021, was not completed in the agency's electronic system until 9/23/2021, 7 business days (9 calendar days) following the visit, making the documentation 5 days late according to agency policy. 3. Patient #5 had a start of care date of 9/5/2021. The Plan of Care, dated 9/5/2021 to 11/3/2021, included orders for skilled nursing services. Clinical record review revealed the following: a. The skilled nurse visit note, dated 9/5/2021, was not completed in the agency's electronic system until 9/12/2021, 5 business days (7 calendar days) following the visit, making the documentation 3 days late according to agency policy. b. The skilled nurse visit note, dated 9/7/2021, was not completed in the agency's electronic system until 9/12/2021, 3 business days (5 calendar days) following the visit, making the documentation 1 day late according to agency policy. c. The skilled nurse visit note, dated 9/15/2021, was not completed in the agency's electronic system until 9/19/2021, 2 business days plus 2 calendar days following the visit, making the documentation 2 days late according to agency policy. 4. Patient #6 had a start of care date of 6/4/2021. The Plans of Care, dated 6/4/2021 to 8/2/2021, included orders for skilled nursing, home health aide and physical therapy services. The Plan of Care , dated 8/3/2021 to 10/1/2021, included orders for skilled nursing services. Clinical record review revealed the following: a. The skilled nurse visit note, dated 6/23/2021, was not completed in the agency's electronic system until 6/28/2021, 3 business days (5 calendar days) following the visit, making the documentation 1 day late according to agency policy. b. The skilled nurse visit note, dated 7/1/2021, was not completed in the agency's electronic system until 7/9/2021, 6 business days (8 calendar days) following the visit, making the documentation 4 days late according to agency policy. c. The skilled nurse visit note, dated 7/21/2021, was not completed in the agency's electronic system until 7/30/2021, 7 business days (9 calendar days) following the visit, making the documentation 5 days late according to agency policy. d. The skilled nurse visit note, dated 8/19/2021, was not completed in the agency's electronic system until 8/25/2021, 4 business days (6 calendar days) following the visit, making the documentation 2 days late according to agency policy. e. The skilled nurse visit note, dated 9/16/2021, was not completed in the agency's electronic system until 9/28/2021, 8 business days (12 calendar days) following the visit, making the documentation 9 days late according to agency policy. 5. Patient #8 had a start of care date of 6/8/2021 and was discharged from the agency on 8/6/2021. The Plan of Care, dated 6/8/2021 to 8/6/2021, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. Clinical record review revealed the following: a. The home health aide visit notes, dated 6/10/2021; 6/14/2021; 6/18/2021; 6/21/2021 and 6/24/2021, were not electronically signed until 7/14/2021. The agency was unable to present previous documentation of the notes. During agency staff interview on 10/6/2021 at 1:10 PM, the Clinical Manager reported the aide had documented the above stated visit notes on a homemaker sheet. The aide later corrected the documentation electronically but destroyed the original documentation. b. The skilled nurse visit note, dated 6/11/2021, was not completed in the agency's electronic system until 6/17/2021, 4 business days (6 calendar days) following the visit, making the documentation 2 days late according to agency policy. The above stated findings for Patients #1, #3, #5, #6 and #8 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review, review of the agency's staff list and agency policy review, the agency failed to ensure authentication of staff documentation in each patient's clinical record included the signature and credentials of the author of the document and the date and time of the signature of the author for 8 of 8 sampled patients (Patient #1, #2, #3, #4, #5, #6, #7 and #8). The agency reported a current census of 27 patients at the time of the survey. Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: According to the agency policy, titled Home Health Documentation and updated 1/2021, entries into patient records shall be made by authorized personnel only; shall be kept up to date from intake through close of the case; and be completed, signed and dated by the person who provided services. All clinical routine visit documentation must be completed, signed and marked permanent by midnight of the 2nd business day following the visit. 1. Patient #1 had a start of care date of 8/27/2021. Clinical record review revealed the following: a. The Plan of Care, dated 8/27/2021 to 10/25/2021, included orders for skilled nursing and physical therapy services. b. The skilled nurse visit notes, dated 8/27, 8/31/2021, 9/3, 9/9, 9/16, 9/23 and 9/28/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated skilled nurse visit notes were completed by a combination of registered nurses and licensed practical nurses. c. The physical therapy visit notes, dated 8/27/2021; and 9/3, 9/8, 9/17 and 9/22/2021, included a hand written signature of the therapist or therapy assistant and date of signature; however, lacked identification of the time of signatures. 2. Patient #2 had a start of care date of 9/16/2021. Clinical record review revealed the following: a. The Plan of Care, dated 9/16/2021 to 11/14/2021, included orders for skilled nursing, occupational therapy and physical therapy services. b. The skilled nurse visit notes, dated 9/16, 9/21and 9/27/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated skilled nurse visit notes were completed by registered nurses. c. The physical therapy visit notes, dated 9/16, 9/21, 9/24, 9/28 and 10/1/2021, included a hand written signature of the therapist or therapy assistant and date of signature; however, lacked identification of the time of signatures. d. The occupational therapy visit note, dated 9/20/2021, included a hand written signature of the author and the date of the signature; however, lacked identification of the credentials of the author and the time of the signatures. The staff list provided by the agency identified the author of the visit note was an occupational therapist. 3. Patient #3 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The Plans of Care, dated 7/24/2021 to 9/21/2021 and 9/22/2021 to 11/20/2021, included orders for skilled nursing and physical therapy services. b. The skilled nurse visit notes, dated 7/27, 8/3, 8/10, 8/11, 8/18, 8/24, 8/31, 9/7, 9/14, 9/17, 9/21, 9/24, 9/27 and 10/1/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated skilled nurse visit notes were completed by a combination of registered nurses and licensed practical nurses. c. The physical therapy visit notes, dated 7/27, 7/29, 8/3, 8/5, 8/12, 8/18, 8/25, 8/27, 8/31, 9/3, 9/8, 9/10, 9/15, 9/21 and 9/28/2021, included a hand written signature of the therapist or therapy assistant and date of signature; however, lacked identification of the time of signatures. 4. Patient #4 had a start of care date of 11/21/2018. Clinical record review revealed the following: a. The Plans of Care, dated 3/10/2021 to 5/8/2021, 5/9/2021 to 7/7/2021, 7/8/2021 to 9/5/2021 and 9/6/2021 to 11/4/2021, included orders for skilled nursing once every 60 days to complete a comprehensive assessment and supervision of the home health aide. b. The comprehensive assessments, dated 5/5/2021, 7/6/2021 and 9/1/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated comprehensive assessments were completed by registered nurses. c. The supervision notes, dated 5/3/2021 and 8/30/3021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated supervisory notes were completed by registered nurses. 5. Patient #5 had a start of care date of 9/5/2021. Clinical record review revealed the following: a. The Plan of Care, dated 9/5/2021 to 11/3/2021, included orders for skilled nursing services. b. The skilled nurse visit notes, dated 9/5, 9/7, 9/9, 9/11, 9/15, 9/17, 9/19, 9/21, 9/23, 9/25, 9/27 and 9/29/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated skilled nurse visit notes were completed by registered nurses. 6. Patient #6 had a start of care date of 6/24/21. Clinical record review revealed the following: a. The Plans of Care, dated 6/24/2021 to 8/2/2021 and 8/3/2021 to 10/1/2021, included orders for skilled nursing and physical therapy services. b. The skilled nurse visit notes, dated 6/7, 6/15, 6/23, 7/1, 7/21, 7/29, 8/4, 8/12, 8/19, 8/26, 9/2, 9/8, 9/16, 9/22, 9/27 and 9/31/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated skilled nurse visit notes were completed by a combination of registered nurses and licensed practical nurses. c. The physical therapy visit note, dated 6/4, 6/12, 6/15, 6/17 and 6/22/2021, included a hand written signature of the therapist or therapy assistant and date of signature; however, lacked identification of the time of signatures. 7. Patient #7 had a start of care date of 4/6/21 and discharged on 10/1/2021. Clinical record review revealed the following: a. The Plans of Care, dated 8/4/2021 to 10/2/2021, included orders for physical therapy services. b. The physical therapy visit notes, dated 8/17/2021; and 9/1,24/2021 and 10/1/2021, included a hand written signature of the therapist or therapy assistant and date of signature; however, lacked identification of the time of signatures. 8. Patient #8 had a start of care date of 6/8/2021 and discharged on 8/6/2021. Clinical record review revealed the following: a. The Plan of Care, dated 6/8/2021 to 8/6/2021, included orders for skilled nursing, occupational therapy and physical therapy services. b. The skilled nurse visit notes, dated 6/8, 6/11, 6/14, 6/21 and 6/25/2021; and 7/2, 7/9, 7/16, 7/22 and 7/30/2021, included an electronic signature of the nurse, date and time of signature; however, lacked identification of the nurse credentials. The staff list provided by the agency identified the above stated skilled nurse visit notes were completed by registered nurses. c. The physical therapy visit notes, dated 6/9, 6/16, 6/22, 6/30, 7/7, 7/8, 7/14, 7/15, 7/19 and 7/27/2021, included a hand written signature of the therapist or therapy assistant and date of signature; however, lacked identification of the time of signatures. d. The occupational therapy visit notes, dated 6/10, 6/17, 6/24, 6/30, 7/8, 7/15, 7/22, 7/29 and 8/5/2021, included a hand written signature/credentials of the author and the date of the signature; however, lacked identification of the time of the signatures. The above findings for Patients #1, #2, #3, #4, #5, #6, #7 and #8 were reviewed with the Clinical Manager. The agency provided no additional information prior to the end of the survey.