Every finding on record at Home Care RN Inc

A complaint investigation, prompted by #CO27423, was completed on 6/28/21. Based on the findings throughout the investigation the agency was found to be substantially out of compliance with two Conditions of Participation: 484.50 PATIENT RIGHTS 484.55 COMPREHENSIVE ASSESSMENT OF PATIENTS Additionally, two standard level deficiencies were cited.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on staff interviews, review of agency documentation, clinical record review and the standard level deficiency referenced to the Condition, it was determined the Condition of Participation PATIENT RIGHTS, was out of compliance. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. G438-Have a confidential clinical record. The agency failed to ensure the patient's right to confidentiality of personal information was protected for 28 of 28 patient clinical records reviewed.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure the patient's right to confidentiality of personal information was protected for 28 of 28 clinical records reviewed, Focus Group Patients (FGP) #1- #28. Findings include: AGENCY POLICY According to the agency policy, "Patient's Rights," dated June 2020, (in pertinent parts); "3. Exercise of Rights and Respect for Property and Person. The patient shall have the right to confidentiality of all records, communications, and personal information. The Agency shall advise the patient, in writing, of the agency's policies and procedures regarding disclosure of clinical information and records." REFERENCE https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html Department of Health and Human Services: "Protected Health Information. The Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information "protected health information (PHI)." "Individually identifiable health information" is information, including demographic data, that relates to: the individual's past, present or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number)." 1. The agency failed to ensure the patient's right to confidentiality. a) Review of the clinical record provided by the agency on 6/18/21, showed FGP #1 was referred to the agency for home health services on 6/10/21 with an order from FGP #1s primary care provider for a start of care (SOC) of 6/12/21. Record review revealed Employee #3 partially completed the SOC OASIS D1 assessment on 6/12/21 which included identifying patient information such as FGP #1's name, address, date of birth and insurance information. Further review of FGP #1's clinical record revealed that Employee #3 did not complete the OASIS D1 assessment while in the presence of FGP #1. b) During an interview on 6/23/21 at 4:04 p.m., Employee #3 stated she started FGP #1's SOC OASIS D1 on 6/12/21, but had not completed it. Employee #3 stated it took her a few days to get through the SOC OASIS D1, specifically she worked on it the following day at home. Employee #3 further stated that she had personal paperwork kept at her home from working with FGP #1 for the past few years at another home care agency. Employee #3 stated she had a handwritten notebook with patient information, insurance, diagnosis, hospitalizations, appointments, transportation, ICD-10, medication lists and if there was a change she would write that information down. Employee #3 stated the information in this notebook was what she used to complete the SOC OASIS D1 for FGP #1. Additionally, Employee #3 revealed that she had shared information with the Agency Administrator prior to the start of care. Specifically, the patient's name, address, phone number, diagnosis, and insurance information. c) During an interview on 6/23/21 at 3:00 p.m., Employee #4 stated that information on FGP #1 was provided to the Agency Administrator on 6/9/21 via a phone call prior to the agency receiving a referral from the patient's primary care provider. When specifically asked what information was provided to the Agency Administrator Employee #4 stated it was the patient's date of birth, primary care provider and address. 2. The agency failed to ensure the patient's right to confidentiality. a) Review of the clinical record provided by the agency on 6/18/21, showed FGP #2 was referred to the agency for home health services on 6/10/21 with a faxed order from FGP #2's primary care provider for a start of care (SOC) of 6/12/21. Record review revealed Employee #3 partially completed the SOC OASIS D1 on 6/12/21 which included identifying patient information such as FGP #2's name, address, date of birth, insurance information. Further review of FGP #2''s clinical record revealed that Employee #3 did not complete the OASIS D1 while in the presence of FGP #2. b) During an interview on 6/23/21 at 4:04 p.m., Employee #3 stated she started FGP #2s SOC on 6/12/21, but had not completed it. Employee #3 stated it took her a few days to get through the SOC OASIS D1, specifically, she worked on it the following day at home. Employee #3 further stated that she had used personal paperwork kept at her home from working with FGP #2 for the past few years at another home care agency. Employee #3 stated she had a handwritten notebook with patient information, insurance, diagnosis, hospitalizations, appointments, transportation, ICD-10, medication lists and if there was a change she would write that information down. Employee #3 stated the information in this notebook was what she used to complete the SOC OASIS D1 for FGP #2. Additionally, Employee #3 revealed that she had shared information with the Agency Administrator. Specifically, the patient's name, address, phone number, diagnosis and insurance information. c) During an interview on 6/23/21 at 3:00 p.m., Employee #4 stated that information on FGP #2 was provided to the Agency Administrator on 6/9/21 via a phone call between the Administrator, Employee #3 and Employee #4 prior to the agency receiving a referral from the patient's primary care provider. When specifically asked what information was provided to the Agency Administrator, Employee #4 stated it was the patient's date of birth, primary care provider and address. 3. The agency failed to ensure the patient's right to confidentiality. a) Review of the clinical record provided by the agency on 6/18/21, showed FGP #3 was referred to the agency for home health services on 6/10/21 with an order from FGP #3's primary care provider for a start of care (SOC) of 6/12/21. Record review revealed Employee #3 partially completed the SOC OASIS D1 on 6/12/21, which included identifying patient information such as FGP #3's name, address, date of birth and insurance information. Further review of FGP #3's clinical record revealed that Employee #3 had not completed the OASIS D1 while in the presence of FGP #3. b) During an interview on 6/23/21 at 4:04 p.m., Employee #3 stated she started FGP #3's SOC on 6/12/21, but had not completed it. Employee #3 stated it took her a few days to get through the SOC OASIS D1, specifically, she worked on it the following day at home. During the same interview Employee #3 stated that she had personal paperwork kept at her home from working with FGP #3 for the past few years at another home care agency. Employee #3 stated she had a handwritten notebook with patient information, insurance, diagnosis, hospitalizations, appointments, transportation, ICD-10, medication lists and if there is a change she would write that information down. Employee #3 stated the information in this notebook was what she used to complete the SOC. Additionally, Employee #3 revealed that she had shared this information with the Agency Administrator. Specifically, the client's name, address, phone number, diagnosis and insurance information. c) During an interview on 6/23/21 at 3:00 p.m., Employee #4 stated that information on the FGP#3 was provided to the Agency Administrator on 6/9/21 via a phone call between the Administrator, Employee #3 and Employee #4 prior to the agency receiving a referral from the patients' primary care providers. When specifically asked what information was provided to the Agency Administrator, Employee #4 stated it was the patient's date of birth, primary care providers and addresses. d) During an interview on 6/24/21 at 11:48 a.m., the Alternate Administrator stated that it was expected that the RN who was completing the SOC OASIS D1 have a computer with them to complete the assessment on site with the patient. It is also expected that each section of the SOC OASIS D1 be reviewed with the patient. Additionally, the Assistant Administrator stated RN#3 should not have had and should not have used information obtained while working at the prior agency to complete the SOC OASIS D1. e) During an interview on 6/24/21 at 1:23 p.m., the Agency Administrator stated that a week before the FGPs transferred to the agency (no specific date provided) he was given information by Employee #3, Employee #4 and Employee #5 about the FGPs housing situations and medication administration. 4. Record review revealed similar findings that the agency failed to ensure the patient's right to confidentiality for FGPs #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on staff interviews, review of agency documentation, clinical record review and the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 484.55, COMPREHENSIVE ASSESSMENT OF PATIENTS, was out of compliance. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. G514 - Registered Nurse (RN) Performs Assessment - The agency failed to ensure a full OASIS D1 Start of Care (SOC) assessment was completed by the RN at the SOC visit for 28 of 28 patients reviewed.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a full OASIS D1 Start of Care (SOC) assessment was completed by the RN at the SOC visit for 28 of 28 patients reviewed (Focus Group Patients #1-#28). Specifically, the agency accepted 28 referrals with SOC dates of 6/12/21 and 6/14/21. The RN completing the OASIS D1 SOC assessments did not assess and review all areas identified in the assessment while at the SOC visit. The SOC assessment was not based on observation of the patient's condition and ability at the time of the assessment without referring back to prior assessments or documentation of status from a prior care setting in which the RN knew the patient. Findings included: AGENCY POLICY The agency policy titled "Patient Admission Criteria/Scope of Practice" (June 2020) read in part: During the initial visit, the admitting professional will: -Provide information relevant to services to be provided so that the patient/caregiver can give informed consent. -Provide verbal and written information about the services covered under the HHA benefit, the scope of services that the HHA will provide, and specific limitations on those services prior to initiating service/care. -Explain and provide a copy of the Written Notice of Home Care Patient Rights, Patient Bill of Rights and obtain patient's signature. -Explain and provide a copy of the Agency Disclosure Notice and obtain patient's signature. -If patient has an advance directive, a copy will be obtained, or the patient's wishes will be documented. The agency policy titled "Initial Assessments/Comprehensive Assessments" (June 2020) read in part: Each patient admitted by the Agency will have appropriate assessments performed and documented. 6. Initial Assessment and Time Frame: An RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home, on the physician-ordered start of care date. When RN services are ordered at the start of care, the RN will conduct the initial assessment. REFERENCE Outcome and Assessment Information Set OASIS-D Guidance Manual, Effective January 1, 2019, Centers for Medicare & Medicaid Services, In Part: General OASIS Item Conventions (Chapter 1- Page 6): 6. Responses to items documenting a patient's current status should be based on observation of the patient's condition and ability at the time of the assessment without referring back to prior assessments or documentation of status from a prior care setting. Several process items require review of documentation of care that occurred at the time of or at any time since the most recent SOC or ROC OASIS assessment. These instructions are included in item guidance for the relevant OASIS items. 1. The agency accepted 23 referrals with the SOC date of 6/12/21 and five referrals with the SOC date of 6/14/21. The RN completing the OASIS D1 SOC assessments failed to assess and review all areas identified in the assessment during the SOC visits with each patient. During interview on 6/23/21 at 4:04 p.m., Employee #3 stated on 6/12/21 she made home visits with each of the 23 patients, and on 6/14/21 she made home visits to the remaining five patients. The visits were to complete the SOC assessment and any care that needed to be done such as medication administration. She stated she spent approximately 15-minutes with each patient because she needed to get them all seen in order to get them opened so there was no break in care. 2. Review of the clinical record on 6/21/21, showed Focus Group Patient (FGP) #3 was referred to the agency for home health services on 6/10/21 with a faxed order from FGP #3s primary care provider for a SOC date of 6/12/21 to open to home care nursing to evaluate and treat. The Change of Provider form was signed by FGP #3 on 6/11/21. Record review revealed Employee #3 saw FGP #3 on 6/12/21 at 11:55 a.m. to 12:10 p.m. (15 minutes) as recorded on the SOC OASIS D1 form, and partially completed page one of the SOC OASIS D1 assessment, leaving pages 2-13 incomplete. Employee #3 also obtained signatures from FGP #3 on SOC paperwork including a form indicating receipt of verbal and written information and that the information had been explained to the patient. The form included the following sections for review and explanation: Consent for Treatment, Authorization to Release Information, Statement to Permit Payment for Home Health Services, Advanced Directives, and Acknowledgments of Review of Patient Rights, the agency's Home Health Care Patient Handbook, Notice of Privacy Practices, OASIS Statement of Privacy Rights, Disclosure Notice, Emergency Preparedness, Infection Control and Safety Education and Surprise Billing Disclosure. 3. Review of the clinical record on 6/21/21, showed FGP #7 was referred to the agency for home health services on 6/11/21 with a faxed order from FGP #7s primary care provider for a SOC date of 6/12/21 to open to skilled nursing two times a day for 60 days. Record review revealed Employee #3 saw FGP #7 on 6/12/21 at 8:07 a.m. to 8:22 a.m. (15 minutes), and partially completed the SOC OASIS D1 assessment. Employee #3 also obtained signatures from FGP #7 on SOC paperwork including a form indicating receipt of verbal and written information and that the information had been explained to the patient. The form included the following sections for review and explanation: Consent for Treatment, Authorization to Release Information, Statement to Permit Payment for Home Health Services, Advanced Directives, and Acknowledgments of Review of Patient Rights, the agency's Home Health Care Patient Handbook, Notice of Privacy Practices, OASIS Statement of Privacy Rights, Disclosure Notice, Emergency Preparedness, Infection Control and Safety Education and Surprise Billing Disclosure. 4. Review of the clinical record on 6/18/21, showed FGP #2 was referred to the agency for home health services on 6/11/21 with an order from FGP #2s primary care provider for a SOC date of 6/12/21 to open to skilled nursing two times a day for 60 days. Record review revealed Employee #3 saw FGP #2 on 6/12/21 at 12:48 p.m. to 1:01 p.m. (13 minutes), and partially completed the SOC OASIS D1 assessment. Employee #3 also obtained signatures from FGP #2 on SOC paperwork including a form indicating receipt of verbal and written information and that the information had been explained to the patient. The form included the following sections for review and explanation: Consent for Treatment, Authorization to Release Information, Statement to Permit Payment for Home Health Services, Advanced Directives, and Acknowledgments of Review of Patient Rights, the agency's Home Health Care Patient Handbook, Notice of Privacy Practices, OASIS Statement of Privacy Rights, Disclosure Notice, Emergency Preparedness, Infection Control and Safety Education and Surprise Billing Disclosure. During an interview on 6/23/21 at 4:04 p.m., Employee #3 stated she started seeing patients the morning of 6/12/21 for SOC OASIS D1 visits. She stated patients had already chosen the agency and signed the Change of Provider form earlier in the week when she was working with them as an employee of the prior agency, so the visits did not not take long. She stated she spent approximately 15 minutes with each patient. She stated she had seen most patients the day before as an employee of the prior agency. RN #3 stated she completed vitals with everyone. Other care needed was completed such as medication administration, blood sugar levels, insulin administration and wound care. RN #3 stated she did not review and read the information in the patient handbook with the patients, she showed them where it was located in the handbook and had them sign the forms. During the same interview, RN #3 stated she finished completing the SOC OASIS D1 assessments at her home during the weekend. Information for the assessments came from paper work she had kept in her home from her prior employment working with the patients for the past few years. She stated she had a personal notebook with notes on patients that included demographic information such as name, insurance, date of birth, diagnosis; medication information and changes and notes on medical appointments and hospitalizations. RN 3# further stated that the way she had completed the assessments was not the normal way to complete a SOC. Generally, the SOC takes 45-60 minutes to complete and all forms and sections of the assessment are reviewed with the patient. During an interview on 6/23/21 at 2:30 p.m., Employee #5 stated during the SOC OASIS D1 home visit the nurses should try to get as much information about the patient as they could. The assessment should be done by completing a body system review and assessment, a review of medications, equipment used and needed, and identifying the care needs. The nurse should have completed the review at the patient's home. The time taken to complete the assessment varies and depends on the needs of the patient. If the nurse was completing wound care then it could take up to three hours for the assessment and care, if just the assessment and medication review or if it is something they have to teach the patient or family it could take anywhere from one hour to three hours. Generally, the first visit should take at least an hour. During interview on 6/23/21at approximately 10:45 a.m., RN #6 was observed and interviewed during a recertification home visit. She stated recertifications generally took 30 minutes to an hour depending on if other tasks were needed like medication box fill or wound care. Initial SOCs generally took 45 minutes to an hour. She stated she had to review all systems, get all the paperwork done and signed and complete the nursing assessment. It is not something to rush through and takes time to do a thorough job. During an interview on 6/24/21 at 11:48 a.m. the Alternate Administrator stated at a SOC OASIS D1 visit the nurse should have reviewed the SOC packet and patient handbook. The nurse should have explained what home care can and cannot do, and made sure the patient wanted the services. The RN should have also discerned that the client is appropriate for Home Care. Additionally, she stated the assessment should have included a review of any information that accompanied the referral such as the H&P from the physician or hospital. She further stated it was the expectation that the nurse would review and complete every section of the SOC OASIS D1 form with the patient present. The nurse should be getting the consent signed, as well as review and obtain signatures for the other forms in the packet. During an interview on 6/24/21 at approximately 1:23 p.m., the Administrator stated that he thought RN #3 understood the process and had known to cover the topics on the SOC OASIS form. At the SOC visit RN #3 should have reviewed the patient handbook and talked about the patient's rights and advanced directives, agency information, on call information, nurse contact information with each patient prior to having them sign off on the consent form. RN #3 should have completed a full patient assessment as well as completed a medication review and medication reconciliation on site at the time of SOC. He further stated that the time taken to complete the assessment depends, it should take 30 minutes to one hour or more to complete the initial SOC visit correctly. Similar findings were found for Focus Group Patients #1, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28.