Every finding on record at Herman Area Hospital District

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on August 26, 2001. During the survey it was determined Hermann Area District Hospital Home Health Agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Hermann Area District Hospital Home Health Agency was completed on August 26, 2021. The agency had 21 current patients. Two condition-level deficiencies were identified during this survey: - 484.60 Condition of Participation: Care planning, coordination of services, and quality of care; and - 484.105 Condition of Participation: Organization and administration of services. A Covid 19 Focused Infection Control Survey was completed in conjunction with the survey with no deficiencies identified related to the Focused Infection Control Survey. A home health agency that is found out of compliance with certain Conditions of Participation evaluated as part of an extended survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at 484.80(f)(3) - see Tag G788.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include the patient has the right to receive all services outlined in the plan of care. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient's Rights and Responsibilities," dated reviewed 07/21, showed, in part, the following: -The agency staff members implement the Patient's Rights and Responsibilities at the initial visit and throughout all visits; -The purpose is to promote the patient's interests and well-being and to ensure that patient's civil and religious liberties are not infringed; -Each patient admitted to the home health agency will be provided verbal notice of patient's rights and responsibilities in the individual's primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second visit from a skilled professional; -The discipline admitting the patient to home health will review the Patient's Rights and Responsibilities with the patient, requests the patient's signature on the Patient's Rights and Responsibilities verification form, give a copy of the signed verification form to the patient, places the original signed verification form given to the patient in the patient's clinical record, and document patient's refusal to sign the Patient's Rights verification form (if refuses); and -Patients are promptly given written information regarding any changes in the Home Health Patient's Rights and Responsibilities. The administrator provided an admission packet for review on 08/23/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's rights to be informed about receiving all services outlined in the plan of care. During an interview on 08/23/2021 at 2:30 PM, the clinical manager stated that he/she also could not find any written information in the patient's rights that they needed to be informed about receiving all services outlined in the plan of care.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit and the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient's Rights and Responsibilities," dated reviewed 07/21, showed, in part, the following: -The agency staff members implement the Patient's Rights and Responsibilities at the initial visit and throughout all visits; -The purpose is to promote the patient's interests and well-being and to ensure that patient's civil and religious liberties are not infringed; -Each patient admitted to the home health agency will be provided verbal notice of patient's rights and responsibilities in the individual's primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second visit from a skilled professional; -The discipline admitting the patient to home health will review the Patient's Rights and Responsibilities with the patient, requests the patient's signature on the Patient's Rights and Responsibilities verification form, give a copy of the signed verification form to the patient, places the original signed verification form given to the patient in the patient's clinical record, and document patient's refusal to sign the Patient's Rights verification form (if refuses); and -Patients are promptly given written information regarding any changes in the Home Health Patient's Rights and Responsibilities. The administrator provided an admission packet for review on 08/23/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be advised of financial liability changes as soon as possible, in advance of the next home health visit and that the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). During an interview on 08/23/2021 at 2:30 PM, the clinical manager stated that he/she could not find the above information written in the patient's rights either.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's Patient Quality Phone Survey form, and interview, the agency failed to document the existence of a complaint and resolution of the complaint. This deficient practice has the potential to affect the safety and rights of all the agency's patients. Findings included: Review of the agency's policy titled, "Patient Complaints Policy," last revised 7/21 showed, in part, the following: - If a patient voices a complaint to a home health agency staff member, the complaint will be passed onto the HADH-HH (Hermann Area District Hospital Home Health) agency administrator and clinical manager, who will investigate the complaint; - The administrator will investigate all complaints made by a patient, patient's representative (if any), and the patient's caregivers and family, including mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries or unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf the home health agency - The administrator will document both the existence of the complaint and the resolution of the complaint. - The administrator will take action to prevent further potential violations, including retaliation, while the complaint is being investigated. During an interview on 08/23/2021 at 12:05 PM, the administrator stated that they had no complaint book. He/she brought in a Patient Quality Phone Survey book which included seven patients called each month with quality questions. Review of the Patient Quality Phone Survey dated May 2021 one of seven patient comments showed when asked if there is room for improvement he/she replied, "The home health ladies are good. The person upstairs over the weekend was no help, rude, etcetera." During an interview with the clinical manager on 08/23/21 at 1:00 PM, he/she stated that there is a complaint file and he/she would get it. The complaint file failed to show any complaints. After showing the clinical manager the response from the patient on the Patient Quality Phone Survey, the clinical manager stated that he/she did not know what the complaint meant and that he/she will go ask the aide (the person that does the phone surveys). During an interview with the clinical manager on 08/23/21 at 2:45 PM he/she stated the complaint was about the agency on-call person at the hospital that takes calls at the hospital switchboard, they were rude per the aide doing the survey. The clinical manager then stated that the administrator was aware and spoke to the switchboard supervisor but did not document anything. The agency failed to document the complaint or resolution on a complaint form. During an interview with the administrator on 08/25/21 at 1:00 PM he/she stated that; - Complaints are reported to the administrator; - The patient is called to investigate the complaint; - The complaint is investigated with the staff; - The patient is called back with findings; and - The complaint is documented on the complaint form. The administrator stated he/she was not aware of the complaint on the Quality Phone Survey dated May 2021.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient's Rights and Responsibilities," dated reviewed 7/21, showed, in part, the following: -The agency staff members implement the Patient's Rights and Responsibilities at the initial visit and throughout all visits; -The purpose is to promote the patient's interests and well-being and to ensure that patient's civil and religious liberties are not infringed; -Each patient admitted to the home health agency will be provided verbal notice of patient's rights and responsibilities in the individual's primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second visit from a skilled professional; -The discipline admitting the patient to home health will review the Patient's Rights and Responsibilities with the patient, requests the patient's signature on the Patient's Rights and Responsibilities verification form, give a copy of the signed verification form to the patient, places the original signed verification form given to the patient in the patient's clinical record, and document patient's refusal to sign the Patient's Rights verification form (if refuses); and -Patients are promptly given written information regarding any changes in the Home Health Patient's Rights and Responsibilities. The administrator provided an admission packet for review on 08/23/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. During an interview on 08/23/2021 at 2:30 PM, the clinical manager stated that he/she agreed with the above findings.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to accurately reflect the patient's status and include relevant patient data in the recertification assessment in one (Record/Patient #6) of five full record reviews. This deficient practice has the potential to affect the comprehensive assessments for all agency patients. Findings included: Review of the agency's policy titled, "Patient Comprehensive Assessment," dated 07/21, showed the comprehensive assessment must include, at a minimum, in part, the following: - The patient's current health, psychosocial, functional, and cognitive status; - The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the home health agency; - The patient's continuing need for home care; - The patient's medical nursing, rehabilitative, social, and discharge planning needs; and - The patient's primary caregiver(s) if any, and other available supports. RECORD/PATIENT #6: Review of the plan of care dated 08/09/2021 to 10/07/2021 showed the patient was admitted on 04/10/2020. He/she had a current diagnosis of Foley catheter change (tube inserted in the urinary bladder to drain urine into a bag continuously). Other diagnoses included, in part, urinary retention (a condition that is characterized by not being able to empty the urinary bladder completely), and multiple sclerosis (a chronic disease that affects the central nervous system, which is the brain, spinal cord, and optic nerves, a person may experience paralysis, vision loss, and mobility problems). He/she was wheelchair bound. Review of the recertification comprehensive assessment dated 08/06/2021 showed: - All the OASIS (Outcome and Assessment Information Set) items were listed on pages 1 through 12 of the follow-up assessment form; - There failed to be any other assessments integrated in pages 1 through 12; - Page 13 of the assessment showed brief assessments of vital signs, pain level rated on the pain scale, and other items such as heart regularity, lungs (congested or clear), dyspnea (shortness of breath-yes or no), skin intact (yes or no), etcetera; - There was a short narrative by the registered nurse; and - The assessment failed to show the patient's current health, psychosocial, functional, and cognitive status, the patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the home health agency, the patient's continuing need for home care, the patient's medical nursing, rehabilitative, social, and discharge planning needs, and the patient's primary caregiver(s) if any, and other available supports. During an interview on 08/25/2021 at 3:20 PM; the clinical manager stated that he/she: - Was not aware the assessment should be any different than it was; - Had not had any training on OASIS since he/she started at the agency; and - Did not have a background in home health nursing.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview the agency failed to ensure that the medication profile was updated with medication changes in three (Records/Patients #1, #2, and #3) of three home visits conducted. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all agency's patients. Findings included: Review of the agency's policy titled, "Medication Administration Record," dated reviewed 07/21, showed, in part, the following: -Home Health Registered Nurse (RN) will complete the medication record upon patient admission to home health; -Interim physician orders are no longer required when the physician orders a medication for a patient through a prescription given directly to the patient or pharmacy, unless the RN has reason to question the new medication it can simply be listed on the medication sheet. Note in the visit report when the new drug is identified and then include on the recertification on the plan of treatment when patient recertified. Education on the new medication should take place as soon as possible; -Skilled nurse will update the medication record/profile with new, changed, or discontinued drugs when the skilled nurse becomes aware of such; and -Review of medications should be done at start of care, weekly, recertification, discharge, and resumption of care at which time the med profile should be updated and initialed by staff member reviewing the medications. RECORD/PATIENT #1: Review of the plan of care dated 06/29/2021 showed the patient was admitted to home health services on 06/29/2021 from a long-term care facility with a diagnosis of Stage II Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising). During a home visit observation on 08/25/2021 at 8:58 AM, the medications were reconciled using a current medication profile supplied by the agency and a list left in the home. This reconciliation showed the following discrepancies: -Gabapentin 300 milligram (mg) daily was still listed on the list left in the home (it had been discontinued 08/05/2021). RECORD/PATIENT #2: Review of the plan of care dated 08/12/2021 showed the patient was admitted to the agency on 08/12/2021 with a left total hip replacement (damaged bone and cartilage is removed and replaced with artificial components). During a home visit observation 08/24/2021 starting at 8:56 AM, the patient's medications were reviewed. The following discrepancies were found: - Agency medication profile showed Norco 7.5/325 mg (milligram) (a narcotic used to treat moderate to severe pain) one every four hours as need for pain; patient stated he/she was no longer taking this medication; and - Agency medication profile failed to show Tylenol or ibuprofen; patient stated that he/she is taking two extra strength Tylenol every four to six hours as needed for pain alternating with ibuprofen 200 mg two tablets every four to six hours as needed for pain. During an interview with the patient during the home observation visit, he/she stated they were taking the medication as per Mercy Hospital discharge instructions. RECORD/PATIENT #3: Review of the plan of care dated 07/29/2021 showed the patient was admitted to home health services on 07/29/2021 from a hospital with a diagnosis of anal fistula (an infected tunnel between the skin and the anus) secondary to his/her Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract). During a home visit observation on 08/24/2021 at 9:08 AM, the medications were reconciled using a current medication profile supplied by the agency and a list left in the home. This reconciliation showed the following discrepancies: -Oxycodone 5 milligram (mg) one tablet every six hours as needed for pain. The patient stated that he/she no longer was on oxycodone; -Doxycycline 100 mg one tablet twice daily. The patient stated that he/she was no longer on doxycycline; and -Bactrim DS 800/160 mg one tablet twice daily. The patient stated that he/she was no longer on Bactrim DS. During an interview on 08/25/2021 at 1:05 PM, the clinical manager stated that the medications should be reviewed at least weekly and the medication profile updated when any meds are new, discontinued, or changed.

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to incorporate the current version of the Outcome and Assessment Information Set (OASIS) items into the recertification assessment in one (Record/Patient #6) of five full record reviews. This deficient practice has the potential to affect a complete recertification comprehensive assessment being done for all agency patients. Findings included: Review of the agency's policy titled, "Patient Comprehensive Assessment," dated 07/21, showed the OASIS data items must be incorporated into the home health agency's assessment. RECORD/PATIENT #6: Review of the plan of care dated 08/09/2021 to 10/07/2021 showed the patient was admitted on 04/10/2020. He/she had a current diagnosis of Foley catheter change (tube inserted in the urinary bladder to drain urine into a bag continuously). Other diagnoses included, in part, urinary retention (a condition that is characterized by not being able to empty the urinary bladder completely), and multiple sclerosis (a chronic disease that affects the central nervous system, which is the brain, spinal cord, and optic nerves, a person may experience paralysis, vision loss, and mobility problems). He/she was wheelchair bound. Review of the recertification comprehensive assessment dated 08/06/2021 showed: - All the OASIS items were listed on pages 1 through 12 of the follow-up assessment form; - There failed to be any other assessments integrated in pages 1 through 12; - Page 13 of the assessment showed brief assessments of vital signs, pain level rated on the pain scale, and other items such as heart regularity, lungs (congested or clear), dyspnea (shortness of breath-yes or no), skin intact (yes or no), etcetera; and - There was a short narrative by the registered nurse. During an interview on 08/25/2021 at 3:45 PM; the clinical manager stated that he/she: - Was not aware the assessment should be any different than it was; - Had not had any training on OASIS since he/she started at the agency; and - Did not have a background in home health nursing.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to: -Write an individualized plan of care that identified patient-specific measureable outcomes and goals, and which is established, periodically reviewed, and signed by a physician (G572); -Ensure that drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner (G580); -Revise the plan of care to reflect current information from the patient's updated comprehensive assessment, and the plan of care failed to contain information concerning the patient's progress toward the measureable outcomes and goals identified (G592); -Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines (G606); -Provide a visit schedule, including frequency of visits to the patient (G614); and -Provide written treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services(G618). This cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

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 policy review, record review, home visit observation, and interview, the agency failed to complete an individualized plan of care that specified the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment in three (Patients/Records #1, #3, and #4) of five full record reviews completed. This deficient practice has the potential to affect accurate and consistent care for all the agency's patients. Findings included: Review of the agency's policy titled, "Plan of Care," dated reviewed 07/21, showed, in part, the following: -The agency will prepare an individualized patient plan of care that identifies patient-specific measureable outcomes and goals, and which is established, periodically reviewed, and signed by a physician or allowed practitioner; -The Individualized Plan of Care shall be documented on the HCFA form 485; -The individualized "patient charts" must include, in part, the following: All pertinent diagnoses, all medications and treatments, safety measures to protect against injury, patient and caregiver education and training to facilitate timely discharge, and patient-specific interventions and education; measureable outcomes and goals identified by the agency and the patient; and -All services will be integrated to assure the identification of individual patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. RECORD/PATIENT #1: Review of the plan of care dated 06/29/2021 to 08/27/2021 showed: -The patient was admitted on 06/29/2021 with admitting diagnosis of Stage II Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) from a skilled nursing facility; and -Other pertinent diagnoses included: bunion right foot (a bony bump that forms on the joint base of the big toe. A bunion is formed when the big toe pushes against the next toe. Tight shoes, foot stress, and arthritis are causes), pain to right foot, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart. This narrowing keeps the valve from opening fully, reducing blood flow to the body and making the heart work harder), and coronary artery disease (damage or disease in the heart's major blood vessels. The usual cause is the buildup of plaque, this causes coronary arteries to narrow, limiting blood flow to the heart), hypertension (elevated blood pressure), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), glaucoma (a group of eye conditions that can cause blindness), macular degeneration (an eye disease that causes vision loss), legal blindness, hearing loss bilateral, weakness, history of falling, personal history of COVID-19, and history of coronary artery bypass graft (CABG) (a surgical procedure used to treat coronary artery disease that diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart). Review of the patient's referral form, showed the following home health services requested: -Skilled nurse; -Physical therapy; and -Occupational therapy. Review of the comprehensive admission assessment, dated 06/29/2021, showed the patient was blind in both eyes and deaf in left ear and hard of hearing in right ear. During the home visit observation on 08/25/2021 at 8:58 AM, the patient used his/her walker and felt his/her way through the home and stated several times that he/she could not hear what was being said, so the nurse would speak louder and into the patient's right ear. Review of the plan of care dated 06/29/2021 to 08/27/2021 failed to show: - Physical therapy evaluation orders; - Occupational therapy evaluation orders; - Parameters for when to notify physician regarding blood pressure or pulse; and - The plan of care failed to be individualized with patient-specific interventions regarding blindness and hearing loss. RECORD/PATIENT #3: Review of the plan of care dated 07/29/2021 showed the patient was admitted on 07/29/2021 with admitting diagnosis of anal fistula (an infected tunnel between the skin and the anus) secondary to his/her Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract). The patient was admitted from the hospital where he/she had abdominal perineal resection and vertical rectus abdominis muscle rotational flap done on 07/19/2021. Other pertinent diagnoses included: peritoneal abscess (the formation of an infected fluid collection encapsulated by fibrinous exudate, omentum (a fold of peritoneum connecting the stomach with other abdominal organs), and/or adjacent visceral organs), pyoderma gangrenosum (a rare condition that causes large, painful sores to develop on your skin), care of colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), hypersensitivity angitis (an inflammatory reaction in a blood vessel, the result of a specific reaction to an antigenic (allergic) substance or other agents to which the individual expresses unusual vascular sensitization), and obesity (overweight). During the home visit observation on 08/24/2021 at 8:58 AM, showed the patient with a colostomy bag to his/her lower left abdomen. Review of the plan of care dated 07/29/2021 to 09/26/2021, showed the following: -DME/Supplies/Services: ostomy supplies and dressings; and -Goals/Rehabilitation Potential/Discharge Plan: patient will experience healing of incisions within cert period with no signs or symptoms of infection and patient will remain competent with colostomy care. Plan discharge when incisions healed; and -The care plan failed to be individualized with patient-specific interventions regarding colostomy care (as to what pouches to use, what skin barrier to use and what wafer to use). RECORD/PATIENT #4: Review of the plan of care dated 04/23/2021 showed the patient was admitted on 04/23/21 with an admitting diagnosis of aftercare urinary- placement of a stent (a tiny tube placed into a hollow structure in your body) into the ureter (tube that carries urine) to allow external drainage of urine from the body. The patient also had a diagnosis of, but not limited to, abdominal (stomach) pain. Review of the plan of care dated 04/23/21 to 06/21/21 showed, in part skilled nursing to assess pain rate and control. The agency failed to establish pain interventions or parameters for when to notify the physician. During an interview with the clinical manager on 08/23/21 at 3:00 PM he/she stated that: - The plan of care should have pain assessment and interventions; and - Every patient should have at least that we (the staff) are checking pain on their plan of care. During the review of the record findings on Patient #1 and Patient #3 on 08/25/2021 at 1:15 PM, the clinical manager stated that: -Physical therapy and occupational therapy evaluations and orders should be on the plan of care; -Blindness and hard of hearing interventions should have been on the care plan; and -Colostomy care and what to use and how to care for the colostomy should have been included on the care plan.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect physician driven care of all agency's patients. Findings included: Review of the agency's policy titled, "Conformance with Physician's Orders," dated as reviewed 07/21, showed in part the following: -Patient care delivered shall be in conformance with physician's orders as evidenced by documentation of visit reports; -All drugs and treatments are administered by agency staff only as ordered by the physician; and -The Registered Nurse (RN) or Therapist immediately records and signs all verbal and telephone orders and obtains the physicians counter signature within 10 days. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 08/12/2021 with a left total hip replacement (damaged bone and cartilage is removed and replaced with artificial components). During a home visit observation on 08/24/2021 starting at 8:56 AM with PTA B (physical therapy assistant), he/she encouraged the patient to utilize ice as needed for hip discomfort to incisional area. Review of the plan of care failed to show an order for ice and review of the medical record showed no physician order for the ice. During an interview with PTA B on 08/24/2021 at 2:20 PM he/she stated that the order for ice should be written on the plan of care and/or it should be written on a physician telephone order to monitor the ice and that typically they (therapy) don't put the ice on the patient. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 07/29/2021 with admitting diagnosis of anal fistula (an infected tunnel between the skin and the anus) secondary to his/her Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract). The patient was admitted from hospital where he/she had abdominal perineal resection and vertical rectus abdominis muscle rotational flap done on 07/19/2021. Other pertinent diagnoses included: peritoneal abscess (the formation of an infected fluid collection encapsulated by fibrinous exudate, omentum (a fold of peritoneum connecting the stomach with other abdominal organs), and/or adjacent visceral organs), pyoderma gangrenosum (a rare condition that causes large, painful sores to develop on your skin), care of colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), hypersensitivity angiitis (an inflammatory reaction in a blood vessel, the result of a specific reaction to an antigenic (allergic) substance or other agents to which the individual expresses unusual vascular sensitization), and obesity (overweight). Review of the skilled nurse visit note written by Licensed Practical Nurse (LPN) A, dated 08/06/2021, showed replaced steri-strips to the bottom end of the abdominal wound. The clinical record failed to show a verbal or written order for the steri-strips. During an interview on 08/24/2021 at 2:25 PM, LPN A said he/she had added steri-strips to the bottom end of the abdominal wound where the wound had opened up and steri-strips were already present. During an interview on 08/25/2021 at 1:15 PM, the clinical manager said there should have been an order for the steri-strips.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the plan of care was revised/updated to address patients' needs for two (Record/Patient #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care," dated reviewed 07/21, showed in part, the following: -The agency will prepare an individualized patient plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician or allowed practitioner; -The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the home health agency as frequently as the patient's condition or needs require, but no less than every 60 days, beginning with start of care date. The agency must promptly alert the relevant physician(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; and -A revision plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measureable outcomes and goals identified by the agency and patient in the plan of care. Any revision to the individualized plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the agency plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 06/29/2021 with admitting diagnosis of Stage II Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) from a skilled nursing facility. The patient also had diagnosis that included: bunion right foot (a bony bump that forms on the joint base of the big toe. A bunion is formed when the big toe pushes against the next toe. Tight shoes, foot stress, and arthritis are causes), pain to right foot, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart. This narrowing keeps the valve from opening fully, reducing blood flow to the body and making the heart work harder), and coronary artery disease (damage or disease in the heart's major blood vessels. The usual cause is the buildup of plaque, this causes coronary arteries to narrow, limiting blood flow to the heart), hypertension (elevated blood pressure), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), glaucoma (a group of eye conditions that can cause blindness), macular degeneration (an eye disease that causes vision loss), legal blindness, hearing loss bilateral, weakness, history of falling, personal history of COVID-19, and history of coronary artery bypass graft (CABG) (a surgical procedure used to treat coronary artery disease that diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart). Review of the clinical record showed: -On 07/08/2021, during a skilled nurse visit the patient had lab drawn and a urinalysis sent to lab; and -On 07/12/2021, the skilled nurse visit showed the patient was started on Cefdine (antibiotic) 300 milligram (mg) twice a day for 7 days for urinary tract infection (UTI) on 07/10/2021. Review of the plan of care showed the agency failed to revise the plan of care to include patient-specific interventions regarding the UTI. During an interview on 08/25/2021 at 1:05 PM the clinical manager stated that the plan of care should have been revised to include patient-specific interventions for the UTI. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 07/29/2021 with admitting diagnosis of anal fistula (an infected tunnel between the skin and the anus) secondary to his/her Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract). The patient was admitted from hospital where he/she had abdominal perineal resection and vertical rectus abdominis muscle rotational flap done on 07/19/2021. Other pertinent diagnoses included: peritoneal abscess (the formation of an infected fluid collection encapsulated by fibrinous exudate, omentum (a fold of peritoneum connecting the stomach with other abdominal organs), and/or adjacent visceral organs), pyoderma gangrenosum (a rare condition that causes large, painful sores to develop on your skin), care of colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), hypersensitivity angiitis (an inflammatory reaction in a blood vessel, the result of a specific reaction to an antigenic (allergic) substance or other agents to which the individual expresses unusual vascular sensitization), and obesity (overweight). Review of the clinical record showed: -On 08/05/2021, the skilled nurse's note showed the abdominal wound had dehisced (a rupture or splitting open, as of a surgical wound); and -On 08/05/2021, a physician's order showed: Increase skilled nurse visits to daily times five to address wound care. Clean abdominal wound with normal saline then pack with normal saline moist to dry dressing secured with tape. Clean rectal wound with normal saline, then dry gauze if needed. Review of the plan of care showed the agency failed to revise/update the patient plan of care to include measureable goals for the dehisced wound. During an interview on 08/25/2021 at 1:15 PM, the clinical manager stated that the plan of care should have been updated to include the dehisced wound with measureable goals.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on policy review, record review, and staff interview, the agency failed to assure integration of services and coordination of care between all disciplines caring for the patient whether provided directly or under arrangement in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of the agency's policy titled, "Coordination of Care," date reviewed 07/21, showed in part, the following: -The agency staff and physicians will work together to coordinate care to ensure of a timely discharge for the patient; -The agency will integrate services, whether services are provided directly or under arrangement, to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines; and -All agency personnel, shall be responsible for communicating pertinent information regarding patient's assessment at visit and/or patient's needs and desires to the physician on the plan of care in order to assist in providing continuity and quality care. Review of the agency's policy titled, "Patient Care Conference," dated reviewed 07/21, showed in part, the following: -Patient care conference will be provided at least monthly by the agency Registered Nurse (RN) Supervisor to discuss the coordination of care and appropriate utilization of services for each patient on service; -Care conferences may be conducted as an informal meeting; -Patients on service must be discussed in care conference at least once every 30 days; -Patient care conference shall be held at least once a month with all involved disciplines, and be held more frequently if necessary. If no group meeting is held, copies of the progress notes may serve as the care conference but all disciplines must review these notes and sign that the care was reviewed. Any special needs/concerns will be documented on a separate form and placed in the patient record and the minutes filed; -Documentation of each patient discussed and staff involved in care conference will be kept in a binder kept in a locked file. Staff will discuss or note pertinent physical, psychological, and environmental information. Evaluate goals and frequency of services rendered for each patient. Appropriateness of services utilized shall be discussed and documented; and -Follow-up of the care conference recommendations will be noted in the patient care plan and with the patient care that is provided unless contradicted by the physician. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 06/29/2021 with an admitting diagnosis of Stage II Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) from a skilled nursing facility. Review of the clinical record showed the following: -A physician's order, dated 06/29/2021 for Physical therapy two times a week for three weeks; -A physician's order, dated 06/30/2021 for Occupational therapy once a week for week one, then twice a week for three weeks; -The plan of care showed skilled nurse visit three times a week for four weeks, then twice a week for three weeks; -The plan of care showed cleanse right foot with normal saline, apply silvadene (topical antibiotic), a 4x4 gauze, and then tape daily; -A physician note, dated 07/01/2021, showed the patient went to the doctor and he/she ordered lab work, discontinued one medication-Amlodipine (calcium channel blocker- used to treat high blood pressure and chest pain), started the patient on another medication- Pentoxifylline (anti-inflammatory and vasodilator), and changed the patient wound order to- Clean right foot with soap and water once per day and apply hydrogel solosite (creates moist wound environment and is water-swellable, allowing it to absorb exudate yet remain gel-like until saturated) twice daily; -On 07/05/2021 Skilled nurse visit showed Gabapentin (anticonvulsant and nerve pain medication) was discontinued; -On 07/07/2021 Skilled nurse visit showed 1+ bilateral lower extremity edema. No documentation the physician was alerted to this change; -On 07/08/2021 Skilled nurse visit showed more lab was drawn along with a urinalysis; and -On 07/12/2021 Skilled nurse visit showed the patient was on antibiotic for urinary tract infection (UTI) that was started on 07/10/2021. Review of the patient's care conference sheet, dated 07/12/2021, showed the following : -Clinical update: wound care on foot, no changes since admission; -Change in Diagnosis or Goals: none; and -Employees present: three nurse's with their first names. Review of the clinical record including nursing, PT, and OT visit notes failed to show interdisciplinary communication about the patient. During an interview on 08/25/2021 at 1:05 PM, the clinical manager said the following: -Usually just nursing was at care conference meetings; and -He/She agreed the above changes should have been discussed with all disciplines and updated on the patient's care conference note.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instruction outlining the visit schedule, including frequency of visits in, but not limited to, two (Records/Patients #1 and #3) of three home visit observations. This deficient practice has the potential to affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Plan of Care," dated reviewed 07/21, showed in part, the following: -Once the comprehensive assessment is completed and the plan of care is approved by the responsible physician including, the agency will provide the patient and/or caregiver with a copy of written instructions outlining the following: -Visit schedule, including frequency, treatments to be done (medications, dressing, therapy, etc.), and personnel acting on behalf of the agency; -Medication schedule/instruction, including: medication name, dosage, frequency, route, purpose, and side effect; and -Any other pertinent instructions related to patient's care and treatments that the agency will provide, specific to the patient's individual care needs. RECORD/PATIENT #1: During a home observation visit on 08/25/2021 at 8:58 AM with the registered nurse, the surveyor observed the patient's home chart. The agency failed to provide a written visit schedule for the patient in the home. RECORD/PATIENT #3: During a home observation visit on 08/24/2021 at 9:08 AM with licensed practical nurse, the surveyor observed the patient's home chart. The agency failed to provide a written visit schedule for the patient in the home. During an interview on 08/25/2021 at 1:05 PM, the clinical manager stated that he/she was not aware that a written visit schedule should be in the patient's home.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in two (Records/Patients #1 and #3) of three home visit observations. This deficient practice has the potential to adversely affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Plan of Care," dated reviewed 07/21, showed in part, the following: -Once the comprehensive assessment is completed and the plan of care is approved by the responsible physician including, the agency will provide the patient and/or caregiver with a copy of written instructions outlining the following: -Any other pertinent instructions related to patient's care and treatments that the agency will provide, specific to the patient's individual care needs. RECORD/PATIENT #1: Review of the plan of care (POC) dated 06/29/2021 through 08/27/2021 showed, in part, the following: -SN three times a week for four weeks then twice a week for three weeks for assessment; -Cleanse wound on right foot with normal saline, apply silvadene (antibiotic), apply 4x4 gauze, and then secure with tape; and -Educate on wound care, infection prevention, signs and symptoms of infection, pressure wound precaution. Review of a physician's order, dated 07/02/2021, showed to cleanse right foot wound with soap and water, apply hydrogel solosite (creates moist wound environment and is water-swellable, allowing it to absorb exudate yet remain gel-like until saturated) and cover with a dry dressing daily. Review of a physician's order, dated 07/26/2021, showed to increase skilled nurse visits to three times a week for five weeks. Review of physician's order, dated 08/17/2021, showed change right foot wound care to cleanse with soap and water and apply dry dressing daily. During a home observation visit on 08/25/021 at 8:58 AM with a registered nurse, the surveyor observed the patient's home admission packet. The agency failed to provide written wound care instructions. RECORD/PATIENT #3: Review of the plan of care (POC) dated 07/29/2021 through 09/26/2021 showed, in part, the following: -SN two times a week for one week, then once a week for seven weeks for assessment; -Assist with colostomy care as needed; -Clean abdominal incision with alcohol swab or soap and water, pat dry, and leave open to air; -Clean rectal incision with normal saline or soap and water; and -Educate on wound care and signs and symptoms of infection. Review of a physician's order, dated 08/05/2021, showed the following: -Increase skilled nurse visits to daily times five to address wound care; -Clean abdominal wound with normal saline then pack with normal saline moist to dry dressing and secure with tape; and -Clean rectal wound with normal saline, then dry gauze if needed. Review of a physician's order, dated 08/11/2021, showed to continue skilled nurse visits daily for wound care. During a home observation visit on 08/24/2021 at 9:08 AM with licensed practical nurse, the surveyor observed the patient's home admission packet. The agency failed to provide written wound care instructions. On 08/25/2021 at 1:05 PM, the records and visits was reviewed with the clinical manager, he/she acknowledged there was no written wound care instructions in the home.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: 484.60-Care planning, Coordination of Services and Quality of Care and 484.105-Organization and Administration of Services, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 08/26/2023.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on review of the agency policies, employee file review, observation, and interview, the agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services when the agency failed to ensure: - The administrator assumed responsibility for all day-to-day operations (G948); - The home health agency employed qualified personnel including assuring the development of personnel qualifications and policies (G952); - The governing body and administrator ensured that a qualified, pre-designated person was authorized in writing by the administrator and the governing body and would assume the responsibilities of the administrator in his/her absence (G954); and - The clinical manager assured the development, implementation, and updates to the individualized plans of care (G968). The cumulative effect of these systemic deficient practices resulted in the inability of the agency to provide effective ongoing management of all clinical services and assure the effective implementation of the plan of care.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on current survey findings, policy review, observation, and interview, it cannot be assured the administrator has effectively assumed responsibility for the overall administration, supervisory functions and overall operations of the home health agency. This deficient practice has the potential to affect all patients receiving services from the agency. Findings included: These deficient practices led to the failure of the agency to comply with two Conditions of Participation: - 484.60 Condition of Participation: Care Planning, coordination of services, and quality of care; and - 484.105 Condition of Participation: Organization and administration of services. Review of the agency's policy titled "Home Health Administrator", dated reviewed 07/21 showed, in part: - The Hermann Area District Hospital (HADH) home health will provide an administrator who shall be the direct representative in the management of the day to day operations of the agency; - The administrator must be responsible for all day to day operations of the home health agency; - Shall be supportive of the HAHD home health philosophy and responsible for carrying out the policies of the HADH home health program; and - Is responsible for organizing and directing the agency's ongoing functions. Observation throughout the survey showed the home health administrator was only physically present in the home health agency after being summoned by the agency staff. During an interview on 08/25/21 at 1:00 PM, the administrator stated that he/she : - Touches base with the agency daily, checking on census, and not really day to day handling of home health activity; - Had attended one or two home health case conferences when he/she first started in 2017 or 2018, but had not been to any recently; - Is there for the agency if they have questions or need further resources; - Had been the administrator since 2018; - Had no background or training in home health; and. - Is not aware of the home health CMS (Center for Medicare and Medicaid Services) regulations.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of employee files, and interview, the administrator failed to ensure the agency hired qualified staff and ensured that adequate staff education was provided. Findings included: Review of the clinical manager employee file (date of hire 12/14/2020), failed to show any specific home health training including, but not limited to, OASIS (Outcome and Assessment Information Set- a standardized comprehensive assessment designed to collect information related to a home health patient's health and functional status) or QAPI (Quality Assessment and Performance Improvement- a data driven proactive approach to improving the quality of care). During an interview 08/24/2021 at 3:10 PM, the clinical manager stated that he/she: - Had no training in OASIS and that he/she had not read the OASIS manual but looked up individual items he/she questioned; and - Had no formal training in QAPI and did not know how to track quality indicators including adverse patient events. During an interview with the administrator on 08/25/2021 at 1:00 PM, the administrator stated that: - The clinical manager had no background in home health; and - The old home health director taught the clinical manager and was still available.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation, and interview, the agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body assumes the same responsibilities and obligations as the administrator when the administrator is not available. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: Review of the employee record showed the clinical manager was hired by the agency 12/14/20. Review of a copy of a letter addressed to the health program representative at the Bureau of Home Care dated 07/21/2021 was provided to the surveyors. The letter showed that: -The agency was advising the State that the hospital board of directors had appointed the clinical director to be the predesignated alternate administrator of the agency; and -The administrator was also approving the appointment of the clinical manager of the agency to be the predesignated alternate administrator of the agency. Review of the monthly governing board minutes from December of 2020 to July of 2021 failed to show documentation from the governing body regarding the approval of the clinical manager to act as the alternate administrator in the absence of the home health administrator. During an interview on 08/24/2021 at 1:45 PM, the administrator stated that he/she was unable to find in the governing body minutes that showed the approval of the clinical manager as the alternate administrator in his/her absence. During an interview on 08/23/21 at 2:55 PM, the clinical manager stated that: - He/she thought the hospital administrator was the alternate home health administrator; and - Later, the clinical manager stated that he/she was aware that he/she is alternate but was not aware that was what it was called and that when the home health administrator is gone he/she is the alternate administrator for home health.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on current survey findings, review of the policy for the clinical manager, and interview, it cannot be assured that the clinical manager has effectively assumed responsibility for the overall supervision and direction of skilled professional services and actively participates in all activities relevant to the professional services furnished, including assuring the development, implementation, and updates to the individualized plan of care. Based on the current survey findings, (a condition level citation of 486.60- Care Planning, Coordination of Services and Quality of Care-G570) the clinical manager failed to: - Ensure completion of individualized care plans that specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment (G572); - Ensure verbal orders are provided that show physician communication and dates that collaborate with the clinical findings (G580); - Ensure plan of care was revised/updated to address patient needs(G592); and - Assure integration of services and coordination of care between all disciplines caring for the patient(G606). Review of the agency's policy titled, "Home Health Clinical Manager" dated revised 07/2021 showed the clinical manager will, in part: - Provide oversight of all patient care services and personnel; - Coordinate patient care; - Coordinate referrals; - Assure that patient needs are continually assessed; - Assure the development, implementation, and updates of the individualized plan of care; and - Be responsible for providing patient care conference to assure that patient ' s goals are being met and that pertinent patient information is communicated to all interdisciplinary staff. Review of the clinical manager's employee file showed a hire date of 12/14/2020. The file failed to show any specific home health training including, but not limited to, OASIS (Outcome and Assessment Information Set-a standardized comprehensive assessment designed to collect information related to a home health patient ' s health and functional status) or QAPI (Quality Assessment and Performance Improvement- a data driven proactive approach to improving the quality of care) for the clinical manager. During an interview with the administrator on 08/25/2021 at 1:00 PM, the administrator stated that: - The clinical manager had no background in home health; and - The old home health director taught the clinical manager and was still available. During an interview on 08/25/2021 at 3:20 PM; the clinical manager stated that he/she: - Had not had training on Outcome and Assessment Information Set (OASIS),the agency infection control program, and quality assessment and performance improvement (QAPI) program since he/she started at the agency; - Had not had training related to implementing and over site of the plan of care; and - Did not have a background in home health nursing.

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 policy review, record review, and interview, the agency failed to provide evidence that a completed comprehensive discharge summary to include all necessary components was sent to the primary care physician after discharge from the agency's services within five business days of the patient's discharge in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to adversely affect the post discharge care of all patients served by the agency. Findings included: Review of the Condition of Participation: Clinical Records 484.110 Interpretive Guidelines states that a discharge summary must be 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 home health agency (if any) within five business days of the date of the order for discharge from the responsible physician. Review of the policy, "Transfer and Discharge," dated reviewed 07/2021 showed: The responsibilities of the licensed nurse/therapist at discharge included in part: - Complete the discharge summary form and write a short summary of the patient status upon discharge, including date and reason; - The completed report is sent to the physician for signature which then serves as the discharge order; and - The policy failed to show that the summary needed to be sent within five business days. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to the home health agency on 06/05/21 with a diagnosis of acute on chronic systolic congestive heart failure (the muscles in your heart are unable to contract or shorten, preventing blood from being pumped effectively out to your body) with orders for skilled nursing, physical therapy and occupational therapy. The patient was discharged from skilled nursing and occupational therapy on 07/01/2021 and was discharged from physical therapy on 07/23/2021. Further review of the clinical record showed: - A completed discharge summary from skilled nursing dated by the nurse 07/01/2021 and signed and dated seven days later by the physician on 07/08/2021; - A completed discharge summary from occupational therapy dated by the therapist 07/01/2021 and signed and dated thirteen days later by the physician on 07/14/2021; and - A completed discharge summary from physical therapy dated by the therapist 07/23/2021 and signed and dated seventeen days later by the physician on 08/09/2021. During an interview on 08/25/2021 at 8:45 AM the clinical manager stated that they usually mail the discharge summaries so they don't have anything showing when they were sent.