Every finding on record at Hawkeye Health Services, Inc.

As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City Location, the Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for complaint #109872-I from 10/21/24 to 10/23/24. The complaint survey identified the following: Condition of Participation 42 CFR 484.60 Care planning, Coordination of Services and Quality of Care was investigated and no condition level deficiency was identified and one standard level deficiency was identified (G572); Condition of Participation 42 CFR 484.50 Patient’s Rights was investigated and no condition level deficiency was identified; and Condition of Participation 42 CFR 484.80 Home Health Aide Services was investigated and no condition level deficiency was identified. The agency reported a current census of 155 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, 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 for Care for 2 of 5 sampled patients. (Patients #2 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: According to the agency policy, titled Care Planning, dated 9/2024, the individualized plan of care is developed for the patient 60-day episode of care and must include discipline-specific visits, frequency and duration; and services the agency or physician may include to obtain desired patient outcomes/goals. The agency will notify the physician and patient of any identified changes in the patient’s condition and obtain physician orders to update the patient’s plan of care. According to the agency policy, titled Physician/Allowed Practitioner Orders, dated 9/2024, all missed visits must be documented within the patient’s medical record to include the reason for the missed visit and physician/allowed practitioner notification unless authorized under specific circumstances that are documented on the plan of care. 1. Patient #5 had a start of care date of 5/23/24 and a discharge date of 9/13/24. Clinical record review revealed: a. Plan of Care, dated 7/22/24 to 9/19/24, included orders for skilled nursing visits twice a week for 2 weeks and once a week for 1 week, and order for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Interim physician order, dated 8/13/24, included skilled nurse visit frequency for twice a week for 5 weeks and once a week for 1 week, with an effective date of 8/11/24. c. Skilled nursing visits, dated 8/1/24 and 8/13/24, identified completed visits. The clinical record lacked documentation of a skilled nurse visit for the week of 8/4/24 through 8/10/24 or documentation of a missed visit. During an interview on 10/23/24 at 10:15 AM, Staff A, Administrator, reported she reviewed the clinical record, a skilled nurse visit was scheduled on the calendar for 8/9/24, was marked as a missed visit, but no missed visit documentation was entered and physician was not notified. d. Skilled nursing visits, dated 7/23/24, 8/1/24, 8/13/24, 8/20/24, 8/30/24 and 9/5/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 2. Patient #2 had a start of care date of 5/27/21. The clinical record review revealed: a. Plan of Care, dated 9/8/24 to 11/6/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Skilled nurse visit notes, dated 9/13/24, 9/27/24 and 10/11/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. The above findings were reviewed with the Administrator.

A Recertification Survey was conducted by the Department of Inspections and Appeals from 1/16/24 through 1/24/24 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 and Appeals conducted a Recertification Survey from 1/16/24 through 1/24/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a census of 183 current patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient interview, and agency staff interview, the agency failed to ensure accurate and through completion of pertinent components of the initial comprehensive assessment for 1 of 3 sampled patients with wounds at start of care and received therapy only services. (Patient #9) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s policy, dated 4/2023, titled Initial and Comprehensive Assessments, each assessment will be performed by a qualified Clinical Associate who has demonstrated verbal/written knowledge of the specific skills needed to perform assessments including specialty assessments (examples: infusion, wound). According to the agency’s policy, dated 11/2022, titled Wound Assessment and Clinical Oversight, The Registered Nurse (RN) performs the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician/allowed practitioner. Physical Therapists (PTs) may perform the initial assessment in therapy-only cases in accordance with State regulations/practice guidelines and as ordered by the physician/allowed practitioner. Wound assessments will be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment will include wound measurements (length x width x depth in centimeters). A case conference must be conducted for any wound with a variance greater than four points on the Bates-Jensen Wound Assessment Tool (BWAT) and documented on the Wound Conference Coordination. Patient #9 had a start of care date, 12/28/2023. Clinical record review revealed the following. a. The initial comprehensive assessment, dated 12/28/2023, completed by the Physical Therapist, lacked the wound assessment including measurements and staging of a wound on the patient’s sacral area. Documentation included the question; does the patient have at least one unhealed pressure ulcer/injury at a stage 2 or higher, documentation indicated no, noted only post sore redness at sacrum. During a staff interview with Staff I, PT, on January 24th at 11:40 am, PT reported typically a wound identified with comprehensive assessment would be communicated to nursing. Therapist will ask for patients verbal permission to snap a photo to send to the nurses/supervisor in the office for additional guidance and/or obtain orders for nursing in the home. New admissions with assessment of the integumentary system, reads through hospital and referral notes for any indication of wounds or skin issues, will ask the patient if there is any wounds or skin issues and typically tries to assess the sacral area and pressure areas for any issues. With the initial comprehensive assessment, Staff I glanced at the sacral area of Patient #9, recalls only noting redness in the sacrum, no open areas. Recalls reading in patient #9 history prior to admission, pressure sore was present maybe a stage 2. Reports the Spouse indicated they were treating the area and it was healed and spouse had no concerns. b. Occupational therapy (OT) Initial assessment, dated 12/29/2023, patient reported having 3 pressure sores on the buttock sacral area, however refused to let OT look at buttock sacral area. Documentation noted spouse is a retired nurse and reported the pressure sores are healing. During staff interview with Staff G, OT, January 23rd 2024 at 9:50 am, OT reported wounds identified in the home are reported to the Director/Clinical managers in the office, any areas of patient concerns also discussed at weekly plan of care meetings on Wednesdays or sooner if indicated. Attempts are made to gain verbal permission to take a photo and send it to the nursing staff in the office. Reported that some therapy only patients want their physician to address any wounds apart from home services. Recalled Patient #9 reporting pressure sores on his sacral area, but refused to allow therapist to look at those areas. Recalls that Patient #9 spouse is a retired nurse who indicated areas were healing, and treating those areas with zinc cream, spouse was not concerned about the areas at all. During an interview with the patient’s spouse, January 23rd at 8:10 am, spouse indicated patient developed a pressure sore during hospitalization. Patient was discharged from the hospital and admitted to a rehab facility, wound was treated with a zinc cream. Patient’s spouse continued to treat the wound with zinc cream upon return to home, reported it was about an inch long and still had some open areas when discharged to home, much of the area surrounding the wound was reddish with some darker purple. Patient’s spouse reported that the wound was difficult to get air to because of the weight loss, and the buttocks were sticking together, rolled up a micro cloth and placed it between his buttocks to keep moisture out, continued zinc cream and wound healed up. Spouse reported to staff in the home, wound was healing and she was taking care of it with no concerns. During a staff interview with the Administrator, January 22nd at 3:15pm, Administrator reported if wounds are identified in therapy only cases, there is communication with herself or another nursing supervisor and a skilled order will be obtained for a nurse to see the patient when that is indicated. During a staff interview with the Administrator, on January 23rd 2024, at 11:18 am, Administrator reported she could not recall any communication about Patient #9 wound from therapy, verified no documentation in clinical coordination notes communicating a wound with Patient #9 between nursing and therapy. Agency failed to identify a wound on the initial comprehensive assessment. The above findings were reviewed with the agency administrator and clinical managers. Agency staff provided no further 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, patient and family member interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet their needs and an accurate list of the patient's current medications for 4 of 17 sampled patients (Patients #3, #5, #6and #7). 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: 4. Patient #3 had a start of care date of 11/5/23. Review of the clinical record revealed the following: a. The POC, dated 12/5/23 to 2/2/24 included the following medications: Acetaminophen 300 mg codeine (narcotic analgesic) 15 mg every 6 hours as needed for pain and Dulcolax (bisacodyl) (laxative) 5 mg daily oral for constipation. b. The agency medication list, dated 1/16/24, included the medications Acetaminophen 300 mg codeine 15 mg every 6 hours as needed for pain and Dulcolax 5 mg daily oral for constipation. c. The assisted living medication list, dated 1/17/24, included the medications Acetaminophen 300 mg codeine 30 mg every 6 hours as needed for pain, effective 11/3/23 and Bisacodyl 10 mg suppository daily as needed for constipation, effective 11/3/23. d. The POC included the following DME: adaptive living aids, CPAP, elevated toilet seat, incentive spirometer, rails/grab bars, shower/tub equipment, support surfaces, wheelchair, dressing-alginate/hydrofiber, cotton applicator, foam, gauze, honey, tubular dressing, skin care topical barrier, skin protectant and wound cleanser. e, During an observation home visit on 1/17/23 at 10:00 AM with Staff D, Licensed Practical Nurse (LPN), the surveyor identified the patient had additional DME which included a hospital bed, wheelchair cushion and walker. During an interview during the same home visit, Staff D identified the patient utilized the DME at the start of home health services. The POC failed to include correct medications and all DME the patient required for use. The above findings were shared with the Administrator and Clinical Manager. No further information provided prior to the end of the survey. 1. Patient #5 had a start of care date of 12/29/23. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care (POC), dated 12/29/23 to 2/26/24, included orders for Metformin (treat high blood sugar) 500 milligram (mg) with instructions for the patient to take two tablets daily, Vitamin C 1000mg with instructions to take 1 tablet daily, Vitamin D3 25 micrograms (mcg) (1,000 unit) tablet with instructions to take 1 tablet daily and Potassium Chloride extended release (ER) 10 milliequivalent (MEQ) Capsule, with instructions to take 1 capsule daily. b. The Client Medication Report printed on 1/16/24 shows Bupropion Hydrochloride (antidepressant) (HCL) Sustained Release (SR) 150 MG tablet, 12 HR SR as an active medication. During a home visit observation on 1/17/24 at 2:30p.m., with Staff E, Physical Therapy Assistant (PTA), an interview with patient’s spouse revealed patient is taking Metformin 500mg, 2 tablets, two times a day per the instructions on the bottle, Vitamin C 500mg chewable tablet 1 time a day, Vitamin D3 50mcg (2000 units) tablets 1 time a day, and Potassium 99mg tablet 1 time a day. Spouse also reported that Bupropion was discontinued in the last 30 days and patient is taking Melatonin, Tumeric, and cranberry supplements. The POC failed to include a complete list of prescribed and over the counter medications with correct doses and frequencies. c. The POC, dated 12/29/23 to 2/26/24, included the following durable medical equipment (DME) used by the patient: tub chair, emergency response system, incontinent supplies, slide board, diabetic supplies, elevated toilet seat, hospital bed, rails/grab bars, shower/tub equipment, walker, walker-rolling, and wheelchair. d. During a home visit observation on 1/17/24 with Staff E, PTA, the surveyor noted the patient was sitting in and utilizing lift chair. The POC failed to identify the DME lift chair. 2. Patient #6 had a start of care date of 1/18/24. a. The POC, dated 1/18/24 to 3/17/24, included the following DME used by the patient: Adaptive living aids, Emergency Response System, grab bars, tub chair, incontinent supplies, cane, elevated toilet seat, rails/grab bars, shower/tub equipment, and walker-rolling. b. During a home visit observation on 1/22/24 at 1:00p.m., with Staff F, Physical Therapist (PT), surveyor noted a heating pad sitting by patient’s chair. Patient reported she used the heating pad for discomfort. The POC failed to identify the DME heating pad. 3. Patient #7 had a start of care date of 12/22/23. a. The POC, dated 12/22/23 to 2/19/24, included the following DME used by the patient: Emergency Response System, Tub chair, shower wand, incontinent supplies, adaptive living aids, elevated toilet seat, rails/grab bars, shower/tub equipment, walker-rolling, wheelchair, wheelchair cushion. b. During a home visit observation on 1/18/22 at 9:00a.m., with Staff G, Occupational Therapist (OT), surveyor observed a urinal with urine in it next to lift chair patient was sitting in. The POC failed to identify the DME urinal and lift chair. Findings include: According to the agency policy, titled Care Planning, dated 1/19/18, the individualized plan of care must include all medications, supplies and equipment required.

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 1 of 2 sampled patients receiving home health aide services (Patient #17). The agency reported patients who received care provided by a home health aide. 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 patient's would receive inappropriate or inconsistent home health aide services. Findings include: According to the agency policy titled Care Planning, dated 9/2022, the RN s responsible for supervising and developing the care plan for the aide or personal care worker when ordered for the patient. The care plan includes tasks with frequency to be performed in addition to other relevant instructions related to the patient assigned. During an interview on 1/23/24 at 9:05 AM the Clinical Manager stated the Registered Nurse creates and reviews the HHA plan of care at least every certification period. Patient #17 had a start of care date of 8/10/23 and discharged from the agency on 8/30/23. a. The Plan of Care (POC), dated 8/10/23 to 10/8/23, included orders for skilled nursing and home care aide services. The POC included aide tasks of assistance with personal care, hygiene and activities of daily living. b. The home care aide (HCA) care plan, dated 8/10/23, included RN assigned tasks to the aide assignment of providing skin care but did not define what type of skin care should be completed by the aide. The HCA care plan failed to included specific instructions for the aide to provide services for the patient. The above findings were reviewed with the Administrator and Clinical Manager. No further information provided prior to the end of the survey.

The Department of Inspections and Appeals conducted a complaint survey, complaint # 61266-C from 12/13/21 through 12/15/21. The complaint survey identified the following allegations related to the Medicare Conditions of Participation: 42 CFR 484.50 Patient Rights was not substantiated and had no identified deficiencies. 42 CFR 484.55 Comprehensive Assessment of Patients was not substantiated, but the survey identified two related standard level deficiencies (See G0536 and G0550). 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care was not substantiated, but the survey identified a related standard level deficient practice (see G0574).

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, review of the assisted living facility medication record and staff interview, the agency failed to ensure agency nursing clinical staff accurately completed a drug regimen review which included a review of all medications taken by the patient within the required time frames as part of the comprehensive assessment for 3 of 5 sampled patients (Patients #1, #4 and #5). The agency reported a census of 232 patients at the time of the survey. Failure to ensure medications reviewed at the time of each drug regimen review are current increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: Review of the agency policy, titled Assessment, dated 2/24/16, identified the initial assessment and each subsequent assessment will include a review of prescription, over-the-counter drugs and herbals the patient is taking. Therapist and social workers will examine and transcribe information from the bottles of medication the patient is taking. All medications will be evaluated for adverse events, duplication of medication therapy, contraindications, and other medication effects. Therapists may perform this review when permitted by the state practice act. When not permitted by the state practice act, the medication list will be sent to the clinical manager, pharmacist or designee to review the medications for contraindications, duplicative therapy, non-compliance, and side effects/adverse reactions with reports to the physician as appropriate. 1. Patient #1 had a start of care date of 9/20/21 and received home health services while residing in an assisted living facility. Review of the clinical record revealed the following: The Plan of Care (POC), dated 11/19/21 to 1/17/22, included physician orders for medications and physical therapy services 1 time per week for 8 weeks. The clinical record included documentation of a drug regimen review (DRR) completed as part of the update to the comprehensive assessment at the time of recertification, dated 11/15/21, and documentation of a DRR completed by a registered nurse, dated 11/16/21. On 12/14/21 at 11:00 AM, during a home visit observation, Staff C, Physical Therapist (PT), asked the patient about pain. The patient reported back pain with movement and reported using a patch on the back to relieve the pain. Staff C, PT, expressed awareness of the patient's use of the pain patch. Staff C, PT, discussed with the patient the use of a new medication, Mirtazapine, to increase appetite. Review of assisted living medication record, dated 12/14/21, identified physician orders for the following medications not found on the home health agency POC for the patient: a. Aspercreme Pad with Lidocaine 4 percent, 1 patch topically to mid-back and change daily, on 12 hours and off 12 hours, apply in the evening and remove in the morning. The physician order had an order date of 10/15/21 and a start date of 10/16/21. b. Bisacodyl suppository 10 milligrams (mg), insert rectally daily as needed for constipation. The physician order had an order and start date of 10/27/21. c. Hemorrhoidal Ointment, apply rectally four times per day as needed for hemorrhoids. The physician order had an order and start date of 2/8/21. d. Hydrocortisone cream 1 percent with Aloe, apply topically to affected area as needed for itching/irritation. The physician order had an order and start date of 8/12/21. e. Milk of Magnesia suspension 1200 mg/ 15 milliliters (ml), 30 ml by mouth once daily as needed for constipation. The physician order had an order and start date of 10/25/21. f. Mirtazapine 7.5 mg tablet, one tablet by mouth daily. The physician order had an order and start date of 11/12/21. g. Mucous Relief 600 mg extended release tablets, one tablet by mouth every 12 hours. The physician order had an order and start date of 10/1/21. h. Enema Ready, insert one device rectally every 24 hours as needed for constipation. The physician order had an order and start date of 11/20/19. The DRR failed to include a review of all medication taken/used by the patient. On 12/14/21 at 12:37 PM, during an interview, the Administrator reported PT and physical therapy assistant staff should be checking the patient's medication list at the assisted living facility with every visit. She explained sometimes the assisted living facility medication list was not always accurate, but confirmed the assisted living facility staff were responsible for administering the patient's medications. 2. Patient #4 had a start of care date of 1/15/2020 and discharged from agency services on 7/7/21. Review of the clinical record revealed the following: a. The POC, dated 5/9/21 to 7/7/21, included physician orders for medications and orders for occupational therapy services. b. The clinical record included documentation of a DRR completed by the occupational therapist (OT) along with the updated to the comprehensive assessment completed at the time of discharge, dated 7/7/21. The OT contacted the patient's physician with the findings from the DRR. c. The clinical record lacked documentation of completion of a DRR by a RN at the time of discharge (with the update to the comprehensive assessment). On 12/15/21 at 9:10 AM, during an interview, the Administrator reported a RN should have completed the DRR at the time of discharge. The therapist provides the information to a RN and the RN completes the DRR based on the information provided by the therapist. 3. Patient #5 had a start of care date of 12/21/2020 and discharged from agency services on 9/13/21. Review of the clinical record revealed the following: The POC, dated 6/9/21 to 8/17/21, included physician orders for medications and an order for skilled nursing services. a. An interim physician order, dated 7/2/21, included orders for occupational therapy services. b. A skilled nursing visit note, dated 8/10/21, included documentation the patient discharged from agency nursing services. c. An update to the comprehensive assessment completed at the time of recertification by an occupational therapist (OT), dated 8/16/21, included documentation the OT completed a DRR. d. The clinical record lacked documentation of a DRR by a RN until 8/24/21 (8 days late). The POC, dated 8/18/21 to 10/16/21, included a physician order for occupational therapy services (no nursing services). An update to the comprehensive assessment completed at the time of discharge by an OT, dated 9/13/21, included documentation the OT completed a DRR. The OT contacted the patient's physician with the findings from the DRR. The clinical record lacked documentation a RN completed a DRR at the time of the patient's discharge from agency services. The Administrator received the above findings and agency staff provided no further 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 clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed all required components of the discharge comprehensive assessment within 2 calendar days of identification of the need to discharge a patient for 1 of 3 sampled patients requiring a discharge comprehensive assessment (Patient #3). The agency reported a census of 232 patients at the time of the survey and discharged 695 patients since 5/1/21. 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: Review of the agency's policy, titled Assessment, dated 2/24/16, identified the staff will complete an update to the comprehensive assessment within 48 hours from the agency or within 48 hours of becoming aware of an unexpected discharge. The comprehensive assessment will include an assessment of each patient's physical, nutritional and psychosocial status (including vital signs). Patient #3 had a start of care date of 4/16/21 and discharged from agency services on 5/8/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/16/21 to 6/14/21, included physician orders for skilled nursing, home health aide, physical and occupational therapy services. b. The clinical record included documentation of a comprehensive assessment completed at the start of care by Staff I, Registered Nurse (RN), dated 4/16/21. c. The clinical record included documentation of a skilled professional assessment visits, dated 4/19/21, by Staff J, Physical Therapist (PT), and, dated 4/19/21, by an Staff K, Occupational Therapist (OT). The clinical record lacked documentation of any other visits made by clinical staff qualified to do a comprehensive assessment after 4/19/21. d. The clinical record included documentation of a visit made by a physical therapy assistant (PTA), dated 5/6/21, and a certified occupational therapy assistant (COTA), dated 5/7/21. The PTA visit, dated 5/6/21, included documentation of vital signs (temperature, pulse, respirations, blood oxygen saturation level and blood pressure). e. A entry in the clinical record, titled RN Discharge Data Collection Only-No Visit Made, dated 5/10/21, included documentation the Administrator completed answers to Outcome and Assessment Information Set (OASIS) questions. The assessment lacked any current physical health assessment information including vital signs. The clinical record lacked documentation of a drug regimen review with the discharge assessment. The clinical record lacked documentation the Administrator had previously assessed the patient or visited the patient's home. On 12/14/21 at 1:51 PM, during an interview, the Administrator reported when the COTA saw the patient on 5/7/21, the patient's family member/power of attorney for health care requested to talk with hospice about services for the patient. The Administrator explained hospice staff went out to talk with the patient on 5/8/21 and admitted the patient to hospice on this date. The home health agency staff were unaware of the patient's hospice admission until 5/10/21. The Administrator completed the discharge assessment based on the comprehensive assessment completed upon admission to agency services. On 12/14/21 at 2:12 PM, during an interview, the Administrator reported the discharge assessment for unexpected discharges is always based on the last comprehensive assessment and completed by an office RN staff. She further qualified this statement to state the office RN staff only completed the discharges if agency staff found out about the discharge after the patient had been admitted to another service, such as hospice or another home health agency. The Administrator expressed being unaware of the requirement of the last qualified clinician in the home needing to complete the discharge comprehensive assessment and the ability to use data collected from other skilled staff in the home, such as vital signs, 5 days previous to discharge if a discharge visit can not be made to the home. The Administrator received the above findings and agency staff provided no further 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 review of clinical record review, home visit observation, assisted living facility medication record, patient interview, assisted living facility staff interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including medications and the identification of medical equipment/supplies used to meet the patient's individualized needs for 3 of 5 sampled patients (Patients #1, #3 and #4). The agency reported a census of 232 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 home care services according to assessed needs and physician orders. Findings include: Review of the agency policy, titled Physician's Orders, dated 5/13/16, identified agency staff base the plan of care (POC) on an evaluation of the patient's immediate and long-term needs. The POC includes all medical equipment and supplies used by the patient and all medications and treatments. 1. Patient #1 had a start of care date of 9/20/21 and received home health services while residing in an assisted living facility. Review of the clinical record revealed the following: The Plan of Care (POC), dated 11/19/21 to 1/17/22, included physician orders for medications and physical therapy services 1 time per week for 8 weeks. The POC included an order for oxygen 2 liters daily without a route of delivery identified or if the patient used oxygen intermittently or continuously. a. On 12/14/21 at 11:00 AM, during a home visit observation with Staff C, Physical Therapist (PT), the surveyor observed the patient was using oxygen via nasal cannula at 4 liters per minute through an oxygen concentrator in the patient's apartment and portable oxygen bottle when ambulating in the hallway. Staff C, PT, asked the patient about oxygen use, and the patient reported not using oxygen all of the time. Staff C, PT, was unaware of the patient's increase in oxygen to 4 liters per minute. On 12/14/21 at 12:35 PM, during an interview, the Assisted Living Facility Nurse for the patient agreed to send the most recent oxygen order on the patient. Review of a physician order maintained by the assisted living facility revealed an order, dated 9/19/19, for oxygen to maintain blood oxygen levels above 90 percent. The order lacked a liter per minute amount/range or a route of delivery. The POC failed to identify a route of delivery. b. Review of assisted living medication record, dated 12/14/21, identified the following medication discrepancies from the patient's POC: 1) The assisted living facility medication record included an order for Levothyroxine 75 micrograms (mcg), one tablet by mouth daily and a start date of 9/20/21. The POC had an order for Levothyroxine 50 mcg, one tablet daily. 2) The assisted living facility medication record included an order for Senna Plus 8.6 mg -50 mg, 2 tablets by mouth twice per day and a start date of 9/20/21. The POC had an order for Senna Plus 8.6 mg-50 mg, 2 tablets by mouth once daily. 3) The assisted living facility medication record included an order for Alprazolam 0.25 mg, one tablet four times per day as needed for tremors, no dose closer than 2 hours and a start date of 9/20/21. The POC had an order for Alprazolam 0.25 mg, one tablet every 6 hours as needed for anxiety. On 12/14/21 at 12:37 PM, during an interview, the Administrator reported PT and physical therapy assistant staff should be checking the patient's medication list at the assisted living facility with every visit. She explained sometimes the assisted living facility medication list was not always accurate, but confirmed the assisted living facility staff were responsible for administering the patient's medications. The POC failed to include accurate medication doses. c. On 12/14/21 at 11:00 AM, during a home visit observation with Staff C, PT, the surveyor observed the patient had an emergency response call button on a necklace and a pulse oximeter (machine used to measure blood oxygen levels). In an interview, during the same home visit observation, the patient reported the emergency response button called assisted living facility staff if needed. The patient explained he/she did not wear the emergency response button necklace in his/her apartment, but did wear it when he/she left the apartment. The patient reported being at the assisted living facility for 5 years. The patient reported having and using the pulse oximeter for 5 years. The POC, dated 11/19/21 to 1/17/22, failed to identify the patient's use of an emergency response button and pulse oximeter. 2. Patient #3 had a start of care date of 4/16/21 and discharged from agency services on 5/8/21. Review of the clinical record revealed the following: a. The POC, dated 4/16/21 to 6/14/21, identified the patient used the following medical equipment and supplies: cane, wheel chair, hospital bed, rails/grab bars, tub equipment, scale, incontinent supplies, walker tray, bedside commode and shower wand. b. The initial evaluation assessment visit completed by a PT, dated 4/19/21, identified the patient also used a long-handled reacher. The POC failed to identify all the medical equipment/supplies used by the patient. 3. Patient #4 had a start of care date of 1/15/2020 and discharged from agency services on 7/7/21. Review of the clinical record revealed the following: The POC, dated 5/9/21 to 7/7/21, included a physician order for oxygen at bedtime. The order lacked a route of delivery (such as mask or nasal cannula). The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 12/30/2020 through 1/6/2021. The survey identified the following deficient practice in relation to emergency preparedness regulations.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the agency's policies and procedures for their emergency preparedness plan and staff interview, the agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency reported a current census of 228 patients. Failure to have a policy and procedure in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's undated policy titled Emergency Preparedness, dated 3/11/2020, identified the policies failed to include a policy and procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. On 1/5/21 at 3:35 PM, during an interview, the Administrator reported she would do a search of the agency's emergency plan policies. On 1/5/21 at 4:47 PM, during an interview, the Administrator reported an inability to find a procedure included in the policy for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. 1/6/21 at 8:30 AM, during an interview, the Administrator reported she had checked with corporate staff, and they confirmed an inability to find language in the policy which addressed a procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Agency staff provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey combined with a recertification survey, was conducted by the Department of Inspections and Appeals from 12/30/2020 through 1/6/2021. The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The survey identified the following standard level deficient practices occurring at the time of the recertification survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to accurately complete a drug regimen review (DRR), including completion of all required components and identification of any findings within the required time frames as part of the comprehensive assessment for 5 of 18 sampled patients (Patients #13, #14, #15, #16 and #17). The agency reported a current patient census of 228 patients. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: According to the agency policy, titled Assessment, last revised 2/24/16, at the time of the initial assessment and each subsequent assessment, prescription, over-the-counter drugs and herbals the patient is taking will be evaluated. Therapist and social workers will examine and transcribe information from the bottles of medication the patient is taking. All medications will be evaluated for adverse events, duplication of medication therapy, contraindications, and other medication effects. Therapists may perform this review when permitted by the state practice act. When not permitted by the state practice act, the medication list will be sent to the clinical manager, pharmacist or designee to review the medications for contraindications, duplicative therapy, non-compliance, and side effects/adverse reactions with reports to the physician as appropriate. During an interview on 12/31/2020 at 9:27 AM the Clinical Manager stated a DRR is completed with any comprehensive assessment and documented in the medication profile. The medication reviewed for and DRR issues including duplicate medications, side effects, drug interactions, and ineffective medications. 1. Patient #13 had a start of care date of 6/24/2020 and a discharge date of 10/7/2020. Clinical record review revealed the following: a. The Plans of Care, dated 6/24/2020 to 8/22/2020 and 8/23/2020 to 10/21/2020, included physician orders for medications. b. Comprehensive assessment completed at discharge, dated 10/7/2020, included documentation a review of medications was performed and the patient was compliant with drug therapy. The DRR lacked documentation of ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy, required elements of the DRR. c. The Client Medication Report lacked a date to identify DRR was completed at the time of discharge on 10/7/2020. 2. Patient #14 had a start of care date of 7/8/2020 and a discharge date of 9/1/2020. Clinical record review revealed the following: a. The Plan of Care, dated 7/8/2020 to 9/5/2020, included physician orders for medications. b. Comprehensive assessment completed at discharge, dated 9/1/2020, included documentation a review of medications was performed and the patient was compliant with drug therapy. The DRR lacked documentation of ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy, required elements of the DRR. c. The Client Medication Report lacked a date to identify DRR was completed at the time of discharge on 9/1/2020. 3. Patient #15 had a start of care of 6/11/2020 and a discharge date of 6/30/2020. Clinical record review revealed the following: a. The Plan of Care, dated 6/11/2020 to 8/9/2020, included orders for medications. b. The transfer to inpatient facility assessment completed at discharge, dated 6/30/2020, included documentation the patient was admitted to the hospital and discharged from the agency but lacked documentation of a DRR. c. The Client Medication Report lacked a date to identify DRR was completed at the time of discharge on 6/30/2020. 4. Patient #16 had a start of care date of 4/25/2020 and a discharge date of 6/2/2020. Clinical record review revealed the following: a. The Plan of Care, dated 4/25/2020 to 6/23/2020, included physician orders for medications. b. Comprehensive assessment completed at discharge, dated 6/2/2020, lacked documentation a DRR was completed. c. The Client Medication Report lacked a date to identify DRR was completed at the time of discharge on 6/2/2020. 5. Patient #17 had a start of care date of 12/19/19 and a discharge date of 2/26/2020. Clinical record review revealed the following: a. The Plan of Care, dated 12/19/19 to 2/16/2020 and 2/17/2020 to 4/16/2020, included physician orders for medications. b. Comprehensive assessment completed at discharge, dated 2/26/2020, included documentation a review of medications was performed and the patient was compliant with drug therapy. The DRR lacked documentation of ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy, required elements of the DRR. c. The Client Medication Report lacked a date to identify DRR was completed at the time of discharge on 2/26/2020. The above stated findings were reviewed with the agency Administrator and 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, agency clinicians failed to complete updates to the comprehensive assessment at recertification in the last 5 days of each certification period for 3 of 5 sampled patients requiring a recertification assessment (Patients #1, #12 and #13). The agency reported a current census of 228 patients. Failure to complete the updates to the comprehensive assessment at recertification in a timely manner increased the potential that patients might not receive services in a timely manner according to assessed needs. Findings include: According to the agency policy, titled Assessment and dated 2/24/16, the office will perform comprehensive reassessments for all patients receiving skilled services as often as the patient's condition warrants but at least within the 5 days prior to the end of each 60-day episode/certification period. All patients must have a comprehensive reassessment during the last 5 days of the episode for patients receiving skilled care. 1. Patient #1 had a start of care date of 9/23/2020. Clinical record review revealed the following: a. The Plans of Care, dated 9/23/2020 to 11/21/2020 and 11/22/2020 to 1/20/21. b. The update to the comprehensive assessment at recertification, dated 11/20/2020, lacked documentation of a review of the patient's medications. The Client Medication Report included documentation of the medication review, dated 11/24/2020, 3 days after the new episode of care began. During an interview on 1/5/21 at 1:50 PM, the Administrator confirmed the drug regimen review (DRR) was completed late and made the comprehensive assessment late. The update to the comprehensive assessment at recertification, dated 11/20/2020, was completed 3 days late. 2. Patient #13 had a start of care date of 6/24/2020 and a discharge date of 10/7/2020. Clinical record review revealed the following: a. The Plans of Care, dated 6/24/2020 to 8/22/2020 and 8/23/2020 to 10/21/2020. b. The update to the comprehensive assessment at recertification, dated 8/21/2020 and electronically signed as completed on 8/27/2020, lacked documentation of a review of the patient's medications. The Client Medication Report included documentation of the medication review, dated 8/27/2020, 5 days after the new episode of care began. The update to the comprehensive assessment at recertification, dated 8/21/2020, was completed 5 days late. 3. Patient #12 had a start of care date of 11/4/2020. Review of the clinical record revealed the following: a. A Plan of Care, dated 11/4/2020 to 1/2/2021, indicated the certification period ended on 1/2/21. b. An update to the comprehensive assessment completed at the time of recertification, dated 12/31/2020, included a signature of completion by the skilled nurse, dated 1/4/2021 (completed 2 days late). On 1/5/21 at 2:24 PM, during an interview, the Administrator explained if the electronic medical record had a signed completion date of 1/4/21, then this was the actual completion date and the nurse completed the assessment late. The Administrator and Clinical Manager received the above findings and agency staff provided no further 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-ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the timely completion of all pertinent components of the update to the comprehensive assessment at the resumption of care within 48 hours of the agency's knowledge of the patient's return home from an inpatient facility for 1 of 4 sampled patients requiring a resumption of care assessment (Patient #11). The agency reported a current census of 228 patients, including 55 patients in the last 6 months (since 7/1/2020) with an update to the comprehensive assessment at the resumption to care. Failure to complete an update of the comprehensive assessment at the resumption of care in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: Review of the agency's policy, titled Assessment, dated 2/24/16, identified the staff will complete an update to the comprehensive assessment for a resumption of care within 48 hours of the patient's return home (or from a physician-ordered resumption date) from a hospital admission of 24 hours or more for any reason other than diagnostic testing. On 12/30/2020 at 3:20 PM, during an interview, the Administrator reported agency staff used a tracking system and met daily in the am to review any patients needing an initial comprehensive assessment or an update to the comprehensive assessment due to the time of resumption of care. The Administrator explained they reviewed a hospital hold report and a designated person calls the hospitals 3 times per week to ensure agency staff do not miss when the hospitals discharge their home health patients. Patient #11 had a start of care date of 9/15/2020. Review of the clinical record revealed the following: The Plan of Care (POC), dated 9/15/2020 to 11/13/2020, included physician orders for skilled nursing services. a. A coordination note, dated 10/12/2020, identified a hospital had admitted the patient to in-patient services. 1) A coordination note, dated 10/14/2020, included documentation the patient was still in-patient at the hospital, but would possibly discharge to home on 10/15/2020. 2) An interim physician order, dated 10/14/2020, included verbal orders obtained by agency nursing staff for the agency to resume home health services. 3) An update to the comprehensive assessment completed at the time of the resumption of care, dated 10/19/2020, included documentation the patient discharged from the hospital on 10/14/2020, but nurse documented agency staff did not get the referral to resume services until 10/19/2020. The nurse signed completion of the assessment on 10/21/2020 (5 days late). On 1/5/21 at 3:27 PM, during an interview, the Administrator agreed agency staff were aware of the patient's discharge from the hospital prior to 10/19/2020, and agreed the agency nurse was late in completing the update to the comprehensive assessment associated with the resumption of care. b. A coordination note, dated 10/21/2020, identified a hospital had admitted the patient to in-patient services. c. The discharge orders from the hospital, dated 10/29/2020, included documentation of a faxed date for the discharge orders from the hospital to the home health agency, dated 10/29/2020 at 10:15 AM. The orders identified the patient discharged from the hospital and included orders for the home health agency to resume services. d. An update to the comprehensive assessment completed at the time of the resumption of care, dated 10/30/2020, included documentation the patient discharged from the hospital on 10/29/2020, but nurse documented agency staff did not get the referral to resume services until 10/30/2020. The nurse signed completion of the assessment on 11/1/2020 (1 day late). On 1/5/21 at 4:21 PM, during an interview, the Clinical Manager reported the nurse went out timely to complete the resumption of care visit, but agreed the nurse did not complete the documentation of the visit within 48 hours of agency staff becoming aware of the patient's discharge from the hospital. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure agency staff contacted the patient's physician to notify the physician of the possible need to make changes due to an inability to follow the plan of care for 3 of 18 sampled patients (Patients #11, #12 and #17). The agency reported a census of 228 patients at the time of the survey. Failure to ensure agency staff contacted the patient's physician to notify the physician of the need to possibly make changes due to an inability to follow the plan of care placed agency patients at risk for not receiving safe and appropriate care and services to adequately meet the needs of the patient. Findings include: Review of the agency's policy, titled Physician Orders, dated 5/13/16, revealed home health agency care and services will follow an individualized Plan of Care (POC) developed by agency nursing staff and the patient's physician. Agency staff will obtain verbal or written orders prior to initiating or changing services. Agency staff will notify the physician if the patient refuses services or treatment or if agency staff provide fewer services than ordered. Agency staff will document the missed visits and physician notification in the clinical record. On 12/30/2020 at 3:20 PM, during an interview, the Administrator reported agency staff notify the primary care physician of any missed visits and document this in the clinical record. The Administrator explained services delivered by the agency followed POC week that ran from Sunday to Saturday. 1. Patient #11 had a start of care date of 9/15/2020. Review of the clinical record revealed the following: a. The POC, dated 11/14/2020 to 1/12/2021, identified the patient had diagnoses of hypertensive heart disease with chronic kidney disease and heart failure and included physician orders for skilled nursing services 1 time per week effective 11/15/2020. The orders included nursing interventions to assess the patient's cardiovascular system, respiratory system, skin, neurological system, urinary and bowel systems, medications and to monitor the patient's pain. b. The clinical record lacked documentation of a skilled nursing visit the week of 11/15/2020 and lacked a reason why or notification to the physician for the missed visit. The patient had a skilled nursing visit on 11/10/2020, and then did not have a subsequent nursing visit until 11/27/2020. On 1/5/21 at 3:27 PM, during an interview, the Administrator confirmed the patient did not receive a skilled nursing visit as ordered the week of 11/15/2020 and staff did not notify the physician. 2. Patient #12 had a start of care date of 11/4/2020. Review of the clinical record revealed the following: The POC, dated 11/4/2020 to 1/2/2021, included physician orders for home health aide services 2 times per week to assist with personal cares effective the week of 11/8/2020. The week of 11/8, 11/15, 11/29, 12/6, 12/13, 12/20 and 12/27/2020 included documentation of one home health aide visit, dated 11/13. The clinical record lacked documentation of physician notification of the missed home health aide visit. On 1/5/21 at 3:28 PM, during an interview, the Administrator confirmed there had been multiple missed home health aide visits and no physician notification of the missed visits. 3. Patient #17 had a start of care date of 12/19/19 and a discharge date of 2/26/2020. Clinical record review revealed: a. A Plan of Care, dated 12/19/19 to 2/16/2020, included physician orders for skilled nursing services once a week for 1 week and twice a week for 8 weeks. b. Skilled nursing visit note, dated 1/13/2020, for the week of 1/12/2020 to 1/18/2020. c. Client coordination note, dated 1/16/2020, included documentation of a missed nursing visit for 1/16/2020 but lacked documentation the physician was notified of the missed nursing visit. d. Skilled nursing visit note, dated 1/30/2020, for the week of 1/26/2020 to 2/1/2020. e. Client coordination note, dated 1/31/2020, included documentation of a missed nursing visit for 1/31/2020 but lacked documentation the physician was notified of the missed nursing visit. The above stated findings were reviewed with the agency Administrator and 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 may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical record review, home visit observation, patient and family interview, facility staff interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including frequency and duration and duration of visits to be made, patient specific interventions, medications, and/or equipment/supplies used to meet the patient's individualized needs for 6 of 18 sampled patients (Patients #3, #4, #7, #8, #10 and #18). The agency reported a current census of 228 patients. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive home care services according to assessed needs and physician orders. Findings include: According to the agency policy titled Physician's Orders, last revised 5/13/16, the plan of care is based on an evaluation of the patient's immediate and long-term needs. It covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral and other appropriate items. 1. Patient #3 had a start of care date of 11/6/2020. The Plan of Care (POC), dated 11/6/2020 to 1/4/2021, identified the patient had a primary diagnoses of dementia. During a home observational visit on 1/4/21 at 3:00 PM with Staff F, Occupational Therapist, patient #3 noted to have Ted hose (antiembolism stockings) in the patient's bathroom. Assisted living facility staff stated the patient does have an order for Ted hose but sometimes refuses to put them on in the morning. Review of the Assisted Living Facility document titled Medication Review Report dated 1/4/21, included orders, effective 2/4/2020, for knee high Ted hose to place on in the morning and remove at hour of sleep. The Plan of Care, dated 11/6/2020 to 1/4/2021, failed to include the Ted hose used by the patient. 2. Patient #7 had a start of care date of 11/7/2020. The POC, dated 11/7/2020 to 1/5/2021, identified the patient had a primary diagnoses of complications of amputation stump. a. During an observational visit on 1/5/21 at 11:00 AM with Staff E, RN, patient #7 noted to have a cam boot on the right foot, cane and identified using a hand held shower and shower chair. The patient stated the cam boot and cane had been in use prior to the start of home health services. Staff E completed a medication review and identified the following medications: Diclofenac (pain medication) 75 milligrams (mg) 2 times a day, aspirin 325 mg daily and tylenol 500 mg 2 times a day. The patient stated the medications had been taken prior to the start of home health services. The Plan of Care, dated 11/7/2020 to 1/5/2021, failed to include the cam boot, cane, hand held shower and shower chair used by the patient. The POC identified aspirin 81 mg daily and tylenol 325 mg 2 tablets every 4 hours as needed and failed to include the medication Diclofenac. Review of the clinical record revealed the following: b. The Plan of Care (POC), dated 11/7/2020 to 1/5/2021, included physician orders for skilled nursing, physical therapy and occupational therapy services. 1) An interim physician order, dated 11/13/2020, included a physician order for home health aide services for assistance with personal cares, hygiene and activities of daily living. 2) An updated POC, dated 1/5/2021, included the interim physician order, dated 11/13/2020, for home health aide services. 3) The clinical record lacked documentation the patient had received home health aide services and lacked documentation of an order to discontinue home health aide services. On 1/5/21 at 3:25 PM, during an interview, the Administrator reported the patient had refused home health aide services. She provided evidence of coordination note, dated 11/7/2020, which identified the patient refused home health aide services and agency staff notified the patient's physician. Agency staff failed to update the POC to accurately reflect the services the patient received. 3. Patient #8 had a start of care date of 12/10/2020. The POC, dated 12/10/2020 to 2/7/2021, identified the patient had a primary diagnoses of COVID-19. During a home observational visit on 1/4/21 at 2:00 PM with Staff D, Physical Therapist, patient #8 noted to wear Ted hose. Family stated the patient had the Ted hose prior to the start of home health services. The Plan of Care, dated 12/10/2020 to 2/7/2021, failed to include the Ted hose used by the patient. 4. Patient #4 had a start of care date of 12/9/2020. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by Staff D, Physical Therapist (PT), dated 12/9/2020, identified the patient was incontinent of urine. b. The Plan of Care (POC), dated 12/9/2020 to 2/6/2021, did not identify the patient used incontinent products for medical supplies. On 1/5/21 at 12:36 PM, during an interview, Staff D, PT, reported the patient had been using incontinent briefs since prior to the start of care. The POC failed to identify all medical supplies used by the patient. On 1/5/21 at 2:24 PM, during an interview, the Administrator reported the electronic record system split out medical supplies from medical equipment. She explained she needed to re-educate her staff on making sure to include medical supplies on the POC. 5. Patient #10 had a start of care date of 11/8/2020. Review of the clinical record revealed the following: a. The POC, dated 11/8/2020 to 1/6/2021, identified the patient used the following medical equipment and supplies: cane, bedside commode, elevated toilet seat, grab bars/rails, reacher, shower/tub equipment, support braces and a wheelchair. b. The home health aide care plan, dated 11/8 and 11/27/2020, included RN instructions to the home health aide to assist the patient with ambulation with the use of a gait belt. The POC failed to identify the patient's use of gait belt. 6. Patient #18 had a start of care date of 10/14/2020. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 10/14/2020, and the update to the comprehensive assessment completed at the time of recertification, dated 12/8/2020, identified the patient was incontinent of urine. b. The POCs, dated 10/14/2020 to 12/12/2020 and 12/13/2020 to 2/10/2021, did not identify the patient used incontinent products for medical supplies. On 1/5/21 at 1:25 PM, during an interview, Staff G, Home Health Aide, confirmed she had been providing home health aide services to the patient since the start of agency services and the patient had been using incontinent products, both a pad and a brief. The POC failed to identify all medical supplies used by the patient. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to administer treatments only as ordered by the physician for 1 of 6 sampled patients with wound care orders (Patient #7). The agency reported a current census of 228 patients. Failure to ensure staff obtain physician orders for administration of treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency's policy, titled Physician's Orders, dated 5/13/2016, identified verbal or written orders must be obtained prior to the provision of services requiring such orders. The plan of care will be developed with the physician and home care staff. Change orders will be obtained to modify physician orders for disciplines, services, office-administered medications, frequency, or duration prior to making the change.Patient #7 had a start of care date of 11/7/2020. Review of the clinical record revealed the following: a. A Plan of Care (POC), dated 11/7/2020 to 1/5/2021, included physician orders for the skilled nurse to change the patient's wound care dressing on the right lateral foot involving a 4th and 5th digit amputation on Mondays and Wednesdays. The order identified the doctor did wound care on Fridays. b. The skilled nursing visit notes for the week of 12/29/2020, dated 12/1 (a Tuesday), and 12/3 (a Thursday), included documentation the nurse completed wound care. The clinical record lacked documentation of any other skilled nursing visits that same week, lacked documentation to explain why the nurse completed wound care on a Tuesday and Thursday rather than a Monday and Wednesday, and lacked physician notification or a change in physician orders. On 1/5/21 at 3:25 PM, during an interview, the Administrator confirmed agency nursing staff had not provided wound care as ordered on a Monday and Wednesday the week of 11/29/2020. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record 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 4 sampled patients receiving home health aide services (Patients #9 and #10). The agency reported a census of 228 patients, including 34 who receive home health aide services. The agency employed 2 home health aides at the time of the survey. 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 patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency's policy, titled Care Planning, dated 10/23/13, identified the registered nurse and/or other appropriate professional who is supervising or managing the care of the patient, will prepare the written instructions for the aide or personal care worker. These instructions will serve as the care plan for the aide or personal care worker. 1. Patient #9 had a start of care date of 8/25/2020. Clinical record review revealed: a. The Plan of Care, dated 10/24/2020 to 12/22/2020, included physician orders for home health aide services 2 times a week. b. The home health aide assignment also known as aide care plan report, dated 10/24/2020, directed the home health aide to perform skin care and foot care every visit. The assignment failed to identify what specifically the home health aide was supposed to do in order to complete these tasks. c. The home health aide visit notes, dated 11/2, 5, 8 and 12/2020, included documentation the aide had completed the tasks skin care and foot care. During an interview on 1/6/21 at 8:15 AM, the Administrator reported the agency did not have a written policy or procedure to define skin care and foot care. The aide assignment was not individualized to the patient's needs.2. Patient #10 had a start of care date of 11/8/2020. Review of the clinical record revealed the following: a. The Plan of Care, dated 11/8/2020 to 1/6/2021, included orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 11/8 and 11/27/2020, included RN instructions to the home health aide to complete the tasks of "skin care" and "foot care ". The assignment failed to identify what specifically the home health aide was supposed to do in order to complete these tasks. On 1/5/21 at 1:25 PM, during an interview, Staff G, Home Health Aide, reported "skin care " on the home health aide care plan meant the home health aide should put lotion on the patient's skin and watch for sores or rashes and "foot care" meant the home health aide should make sure to clean between the patient's toes. On 1/5/21 at 2:24 PM, during an interview, the Administrator reported "skin care" on the home health aide care plan meant the home health aide needed to apply non-medicated lotion to the patient's skin after the shower or lotion on the patient's back and "foot care" meant the home health aide needed to apply lotion to the patient's feet and make sure the feet were clean. She reported the agency did not have a written protocol in place for doing skin and foot care. The RN failed to ensure the home health aide care plan was individualized and specific to the patient. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 4 of 18 sampled patients (Patients #7, #12, #14 and #16). The agency reported a census of 228 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's policy, titled Assessment, dated 2/24/2016, identified at least weekly, the wound status will be observed and documented, including dimensions (length, width, depth). The patient is assessed on an ongoing basis by the appropriate discipline(s) to evaluate the appropriateness of care; determine additional learning needs, abilities, and readiness to assume self-care; assess the patient's need and verify desire for care; and the appropriateness of the site in which care is delivered. During an interview on 12/31/2020 at 9:27 AM, the Clinical Manager reported wounds are measured weekly and upon discovery, wound measurements will include length, width, depth and will be documented on a wound tool in the electronic medical record. 1. Patient #14 had a start of care date of 7/8/2020 and a discharge date of 9/1/2020. Clinical record review revealed: a. The Plan of Care (POC), dated 7/8/2020 to 9/5/2020, included orders for skilled nursing to assess wounds twice a week for one week and three times a week for 8 weeks. b. The skilled nursing visit notes, dated 7/13/2020, 7/15/2020 and 7/17/2020, included documentation wounds were assessed and wound care performed as ordered but lacked documentation of wound measurements. The clinical record lacked documentation of wound measurements for the week of 7/12/2020 to 7/18/2020. 2. Patient #16 had a start of care date of 4/25/2020 and a discharge date of 6/2/2020. Clinical record review revealed: a. The POC, dated 4/25/2020 to 6/23/2020, included orders for skilled nursing visits weekly. b. The skilled nursing visit note, dated 5/19/2020, included documentation of wound assessment and wound care performed as ordered but lacked documentation of wound measurements. The clinical record lacked documentation of wound measurements for the week of 5/17/2020 to 5/23/2020.3. Patient #7 had a start of care date of 11/7/2020. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 11/7/2020 to 1/5/2021, included physician orders for physical therapy services. 1) The physical therapy evaluation visit note, dated 11/10/2020, included documentation a physical therapist completed the evaluation visit. 2) The subsequent physical therapy visit note, dated 11/19/2020, included documentation a physical therapist completed the visit note and completed supervision of the services a physical therapy assistant (PTA) had provided to the patient. The physical therapist documented the PTA had observed agency infection control policies, honored patient rights and the patient was satisfied with the services provided by the PTA. 3) The clinical record lacked documentation a PTA had provided services to the patient prior to 12/1/2020. The physical therapist inaccurately documented supervision of services provided by a PTA. b. The POC, dated 11/7/2020 to 1/5/2021, included physician orders for skilled nursing services and for the skilled nurse to change the patient's wound care dressing on the right lateral foot involving a 4th and 5th digit amputation on Mondays and Wednesdays. 1) A skilled nursing visit note completed by a licensed practical nurse (LPN) on 12/21/2020, included documentation the nurse assessed the patient had a new stage 2 pressure ulcer (shallow opening or blister caused by pressure, moisture and/or friction) on the patient's right heel. The LPN documented notifying the registered nurse (RN) case manager, but did not measure the wound. 2) A skilled nursing visit note completed by a RN, dated 12/23/2020, included documentation the nurse had assessed the patient's surgical incision on the right foot, but did not address the stage 2 pressure ulcer on the right heel. 3) A skilled nursing visit note, dated 12/28/2020, included documentation the LPN assessed the stage 2 pressure wound on the right heel had healed. The nurses failed to fully assess the right heel wound by measuring the length, width and depth of the wound. 4) A coordination note, dated 12/23/2020, identified the note as a case conference note, included documentation the patient had a new stage 2 pressure ulcer to the right heel that required skilled wound care. The clinical record lacked documentation of any wound care orders for the right heel. On 1/5/21 at 3:25 PM, during an interview, the Administrator agreed the nurses had not measured the right heel wound and could not find any wound care orders for the right heel. 4. Patient #12 had a start of care date of 11/4/2020. Review of the clinical record revealed the following: a. The POC, dated 11/4/2020 to 1/2/2021, included physician orders for home health aide services 2 times per week. b. The home health aide care plan, dated 11/4/2020, included RN instructions to the home health aide to assist the patient with ambulation. c. A home health aide visit note, dated 11/21/2020, included documentation the home health aide followed her assignment and assisted the patient with ambulation. d. A case coordination note, dated 11/23/2020, identified the coordination note as a missed visit notification note, reported a missed home health aide visit on 11/21/2020, and agency staff notified the physician of the missed visit. The home health aide documented the patient refused home health aide services on 11/21. The clinical record lacked accurate documentation of interventions provided during the home health aide visit or inaccurate notification to the physician of a missed visit. The Administrator and Clinical Manager received the above findings and agency staff provided no further 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 patient clinical record review, agency policy review and staff interview the hospice failed to ensure all clinical entry notes included a date and time and staff signature with title for 12 of 18 sampled patients (Patients #1, #2, #6, #7, #10, #11, #12, #14, #15, #16, #17 and #18). The agency reported a current census of 228 patients at the time of the survey. Failure to ensure all clinical record documentation was dated, timed and signed with staff title, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the agency policy titled, Clinical Record Contents, last revised 3/30/16, all notes will be signed and dated, or an electronic signature will be used as appropriate and allowed by state law. During an interview on 1/6/21 at 8:40 AM the Administrator stated the expectation is to include staff signatures with titles, date and time.1. Patient #6 had a start of care date of 10/9/18. Review of the clinical record revealed the following: The skilled nursing visit notes, dated 11/12 and 12/9/2020, included documentation a staff person signed the completion of the visit notes, but lacked a title for the person who completed the notes. 2. Patient #7 had a start of care date of 11/7/2020. Review of the clinical record revealed the following: The skilled nursing visit notes, dated 11/16, 11/18, 11/24, 12/1, 12/3, 12/7, 12/14, 12/21, 12/23, 12/28 and 12/30/2020, included documentation a staff person signed the completion of the visit notes, but lacked a title for the person who completed the notes. 3. Patient #10 had a start of care date of 11/8/2020. Review of the clinical record revealed the following: The skilled nursing visit notes, dated 11/18, 12/8 and 12/15/2020, included documentation a staff person signed the completion of the visit notes, but lacked a title for the person who completed the notes. 4. Patient #11 had a start of care date of 9/15/2020. Review of the clinical record revealed the following: The skilled nursing visit notes, dated 11/6, 11/10, 11/13, 11/27, 12/4, 12/10, 12/17, 12/24 and 12/31/2020, included documentation a staff person signed the completion of the visit notes, but lacked a title for the person who completed the notes. 5. Patient #12 had a start of care date of 11/4/2020. Review of the clinical record revealed the following: The skilled nursing visit notes, dated 11/24, 12/9 and 12/21/2020, included documentation a staff person signed the completion of the visit notes, but lacked a title for the person who completed the notes. 6. Patient #18 had a start of care date of 10/14/2020. Review of the clinical record revealed the following: The skilled nursing visit note, dated 12/8/2020, included documentation a staff person signed the completion of the visit note, but lacked a title for the person who completed the note. On 1/5/21 at 2:24 PM, during an interview, the Administrator reported she realized when the surveyor had asked for skilled nursing visit notes to be printed, the visit notes were missing the title for 2 of her nursing staff. 7. Patient #1 had a start of care date of 9/23/2020. Clinical record review revealed the skilled nursing visit notes, dated 11/4, 11, 28/2020, 12/10 and 18/2020, included the name of the author of the document but failed to include the title of the author making the authentication of the documents incomplete. 8. Patient #2 had a start of care date of 12/12/2020. Clinical record review revealed the skilled nursing visit notes, dated 12/18/2020 and 1/2/21, included the name of the author of the document but failed to include the title of the author making the authentication of the documents incomplete. 9. Patient #14 had a start of care date of 7/8/2020 and a discharge date of 9/1/2020. Clinical record review revealed the skilled nursing visit notes, dated 7/20, 27, 30/2020, 8/3, 6, 11, 14, 20 and 25/2020, included the name of the author of the document but failed to include the title of the author making the authentication of the documents incomplete. 10. Patient #15 had a start of care date of 6/11/2020 and a discharge date of 6/29/2020. Clinical record review revealed the skilled nursing visit note, dated 6/22/2020, included the name of the author of the document but failed to include the title of the author making the authentication of the document incomplete. 11. Patient #16 had a start of care date of 4/25/2020 and a discharge date of 6/2/2020. Clinical record review revealed the skilled nursing visit notes, dated 5/1, 11 and 26/2020, included the name of the author of the document but failed to include the title of the author making the authentication of the documents incomplete. 12. Patient #17 had a start of care date of 12/19/19 and a discharge date of 2/26/2020. Clinical record review revealed the skilled nursing visit note, dated 12/30/2020, included the name of the author of the document but failed to include the title of the author making the authentication of the document incomplete. The above stated findings were reviewed with the agency Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.