Every finding on record at Henderson County Health Depart

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/28/2023. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 7/28/2023. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: PT- Physical Therapy OT- Occupational Therapy -

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 1 of 7 (Pt #7) patients records reviewed, the Agency failed to ensure the physician was notified of changes in the patients condition. Findings include: 1. The clinical record was reviewed for Pt #7 on 7/26/23. Pt #7 was admitted on 6/8/23 with a Diagnoses of Dementia, Diabetes and Left Humerus Fracture. The Plan of Care dated 6/8/23 noted "Home Health Nurse to report to physician/ provider any abnormal assessments, complications or changes..." The blood sugar on 6/16/23 was 401 and on 6/23/23 the skilled nurse noted "checked blood glucose and it was so high that meter read high." The record lacked documentation the physician was notified of the blood sugar of 401 on 6/16/23 and on 6/23/23 blood sugar to high to read. 2. During an interview on 7/28/23 at approximately 1:00 PM with the Director of Nursing (E #4) verbally agreed the blood sugars were elevated and the physician should have been notified for any blood sugar less than 60 or above 350 per Agency protocol.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined for 1 of 5 patient's (Pt.#6) receiving therapy services, the Facility failed to provide a Physical Therapy (PT) and Occupational Therapy evaluation as ordered by the physician in a timely manner. Findings include: 1. The clinical record of Pt. #6 was reviewed on 7/26/23. Pt. #6 was admitted on 6/8/23 with a Diagnosis of Cerebral Infarction. The Plan of Care dated 6/8/23 noted an order for the PT and OT to evaluate and treat the patient, start effective date 6/8/23. The PT's initial evaluation was conducted 6/16/23. The OT's initial evaluation was conducted 6/13/23. 2. During an interview with the Director of Nursing (E#4) on 7/27/23 at 1:00 PM, E#4 verbally confirmed the PT and OT evaluations were late and should have been conducted within 24-48 hours of physician order per Agency protocol.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined in 1 of 7 (Pt #4) patient records reviewed, the Agency failed to ensure patients clinical notes were completed and incorporated into the clinical record in accordance with the agency's policy. Findings include: 1. On 7/27/2023 the Agency policy titled "Clinical Documentation" (implementation 4/7/2020) was reviewed. The policy noted, "Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within seven days after the care has been provided. 2. Pt #4 SOC: 1/30/2023 Diagnosis: Longstanding Persistent Atrial Fibrillation. The record was reviewed on 7/6/2023. The "Skilled Nurse Visit Note" dated 6/22/2023, 7/5/2023 and 7/19/2023 and the 6/30/2023 Oasis Nursing Service Resumption of Care, were not completed and were not incorporated into the patients record as of 7/26/2023, greater than the required 7 days. 3. On 7/27/2023 an interview was conducted with the Director of Nursing (E #4). E #4 reviewed the Visit Notes and the Oasis Nursing Resumption of Care, and verbally agreed they lacked the required documentation.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 1 of 4 (Pt #4) patient record reviewed, who received Home Health Aide (HHA) services greater than 14 days, the Agency failed to ensure HHA supervision was conducted at least every 14 days. Findings include: 1. On 7/27/2023 the policy titled "Home Health Aide Supervision" (implementation 4/7/2022) was reviewed. The policy noted "When skilled services are being provided to a client, a registered Nurse/Therapist must make a supervisory visit to the client's residence no later than every 14 days." 2. Pt #4 SOC (Start of Care): 1/30/2023 Diagnosis: Longstanding persistent Atrial Fibrillation. The record was reviewed on 7/26/2023. A Physician Order dated 3/11/19 noted HHA services once weekly for 9 weeks. Between 6/14/2023 and 7/14/2023, 5 HHA visits were conducted. As of 7/27/2023, the record lacked documentation of a supervisory visit required on 6/14/2023 and 7/14/2023. 3. On 7/27/2023 an interview was conducted with the Director of Nursing (E #4). E #4 verbally agreed a supervisory visits were not conducted and should have been on 6/14/2023 and 7/14/2023.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined for 1 of 1 (Pt# 4) patient transfer of care record reviewed. that the Agency failed to complete the transfer of care within 2 days after inpatient admission to the Hospital. Findings include: 1. Pt #4 SOC:1/30/2023 The clinical record was reviewed on 7/27/2023. A hospital discharge summary dated 6/29/2023 indicated Pt #4 had been admitted to the hospital on 6/26/2023 and discharged on 6/29/2023. Pt #4's record lacked documentation of a OASIS Transfer, therefore the physician was not notified. 2. On 7/27/2023 an interview was conducted with the Office Manager (E #2). E #2 verbally agreed the transfer of care should have been completed within 2 days of a known hospital admission.