Every finding on record at Home Health Care Professionals Inc

A recertification survey was completed on 8/3/23. Based on findings and ongoing investigation due to the scope of deficient practice identified, three Conditions of Participation were determined to be out of compliance: 484.60- CARE PLANNING, COORDINATION OF CARE AND QUALITY OF CARE 484.65- QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT 484.105- ORGANIZATION AND ADMINISTRATION OF SERVICES In addition, 12 standard level deficiencies were cited. Refer to CFR 484.36(a)(2)(i) guidelines. An agency, which has a Condition of Participation out of compliance with any of the requirements is precluded from conducting (if approved) or applying to conduct a Nurse Aide Training Program or Competency evaluation for two (2) years from the exit date.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each beneficiary who received medicare, a medicare advantage plan, and/or medicaid's Outcome and Assessment Information Set (OASIS) was electronically encoded and transmitted to the Centers for Medicare and Medicaid Services (CMS) in 7 of 7 active patient records reviewed (Patients #1, #2, #3, #4, #5, #6 and #7). Findings include: 1. The clinical record for Patient #1 was reviewed on 7/26/23. The POC for the certification period 4/21/23 to 6/19/23 revealed a start of care date of 3/13/19; diagnosis included paraplegia, type two diabetes, neuromuscular dysfunction of bladder, fitting and adjustment of urinary device, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, hereditary factor VIII deficiency, hypothyroidism, fracture of right and left femurs. Plan of care orders included skilled nursing (SN) one to two times every two weeks for nine weeks depending upon the patient status for assessment, education, obtain lab specimens as ordered, change suprapubic catheter every two to three weeks as needed for occlusion, dislodgement, or malfunction of catheter; physical therapy (PT) evaluation and treatment one time a week for nine weeks for assessment and education to improve safety and functional mobility independence; occupational therapy (OT) evaluation and treatment one to two times per week for nine weeks for assessment and education regarding ADLs and safety; speech therapy (ST) evaluation and treatment (no further information provided on the POC for ST interventions); and home health aide (HHA) two times a week for nine weeks to provide assistance with personal care and ADLs. a. The agency failed to ensure Patient #1's OASIS was transmitted to CMS. On 7/26/23, review of the current patient census provided by the agency revealed Patient #1 had a Medicare advantage plan. On 7/26/23, review of the recertification OASIS assessments for Patient #1 dated 4/18/23 and 6/19/23, resumption of care (ROC) OASIS completed on 6/13/23 and the ROC completed on 6/27/23, Patient #1 was identified to have private insurance. On 8/2/23, review of the patient roster in which the agency was transmitting OASIS revealed 14 patients; Patient #1 was not a patient who was noted to have OASIS transmitted to CMS. 2. The clinical record for Patient #2 was reviewed on 7/26/23. The POC for the certification period dated 6/16/23 to 8/14/23 revealed a start of care date of 6/20/23; diagnosis included elevated white blood cell count and type two diabetes mellitus. Plan of care orders included PT evaluation and treatment one to two times a week for eight weeks. a. The agency failed to ensure Patient #2's OASIS was transmitted to CMS. On 7/26/23, review of the current patient census provided by the agency revealed Patient #2 had a Medicare advantage plan. On 7/26/23, record review of the OASIS assessment for start of care (SOC) completed on 6/20/23 revealed Patient #2 had private insurance. On 8/2/23, review of the patient roster in which the agency was transmitting OASIS revealed 14 patients; Patient #2 was not a patient who was noted to have OASIS transmitted to CMS. 3. The clinical record for Patient #5 was reviewed on 7/26/23. The POC for the certification period dated 6/5/23 to 8/3/23 revealed a start of care date of 6/5/23; diagnosis included unspecified open wounds on the right and left leg, repeated falls, degenerative disease of the nervous system, osteoarthritis, hypertension, major depressive disorder, osteoporosis, immunodeficiency, cachexia, and other abnormalities of gait and mobility. The plan of care orders included SN one to two times per week for nine weeks depending upon patient condition for assessment, patient education, lab collection (PRN)/ordered, compliance with medication, and wound care; PT evaluation and treat one time a week for nine weeks for assessment, gait training, education on safety precautions, pain management, strengthening/conditioning exercises, balance/coordination training, and transfer training; OT evaluation and treat one time a week for nine weeks for assessment, ADL training, safety precautions, pain management, and strengthening/conditioning exercises; and HHA two times a week for nine weeks for assistance with personal care and ADLs. a. The agency failed to ensure Patient #5's OASIS was transmitted to CMS. On 7/26/23, review of the current patient census provided by the agency revealed Patient #3 had a Medicare advantage plan. On 7/26/23, record review of the OASIS assessment for SOC completed on 6/5/23 revealed Patient #5 had private insurance. On 8/2/23, review of the patient roster in which the agency was transmitting OASIS revealed 14 patients; Patient #5 was not a patient who was noted to have OASIS transmitted to CMS. 4. Similar findings of the failure to ensure all beneficiaries' OASIS data was transmitted to CMS was revealed in the records of Patients #3, #4, #6 and #7. 5. During an interview on 8/1/23 at 1:32 p.m., the administrative assistant stated she assisted clinicians by completing demographic information in OASIS templates for patients. The administrative assistant reviewed the current census and identified the agency had 14 traditional fee for service medicare patients; however, the majority of the 90 total patients receiving care from the agency had a Medicare advantage plan. The administrative assistant stated the Medicare advantage plans had not required OASIS transmissions and therefore the agency had marked private insurance for these patients. During an interview on 8/2/23 at 11:52 a.m., the bookkeeper at the agency stated it was his responsibility to transmit all OASIS assessments to CMS and that he currently transmitted OASIS for 14 patients at the agency. The bookkeeper further stated he only transmitted OASIS assessments for patients who were on traditional fee for service Medicare. During further interview with the bookkeeper, the administrator joined the discussion related to OASIS transmissions and stated OASIS was not required to be transmitted for Medicare advantage plans as those plans have stated they do not require transmission for that insurance provider. The surveyor provided education regarding OASIS regulation to transmit OASIS on all beneficiaries of the agency.

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 an initial assessment was provided within 48 hours of referral by a physician for 2 of 10 patients reviewed (Patients #2 and #10). Findings include: 1. The clinical record for Patient #2 was reviewed on 7/26/23. The plan of care (POC) for the certification period dated 6/16/23 to 8/14/23 revealed a start of care date of 6/20/23 (inaccurate certification dates- Cross reference G574); diagnosis included elevated white blood cell count and type two diabetes mellitus. Plan of care orders included physical therapy (PT) evaluation and treatment one to two times a week for eight weeks. a) The agency failed to complete a comprehensive assessment within 48 hours of receipt of the referral for Patient #2. Specifically, the agency completed the assessment seven days after receipt of the referral. Review of referral documentation showed on 6/12/23 Patient #2's primary care physician (PCP) ordered occupational therapy (OT) and PT and the agency received this referral document via fax on 6/13/23 at 9:35 a.m. Review of the clinical record revealed OT #4 completed a comprehensive assessment with Patient #2 on 6/20/23, seven days after the agency received the referral. Review of interim orders failed to show a delayed start of care order for 6/20/23. Review of communication notes failed to show why Patient #2's start of care was delayed seven days after the agency's receipt of the referral. During an interview on 8/1/23 at 11:21 a.m., OT #4 stated the administrator or alternate administrator would inform her when she had orders for a new patient either by phone or a text message. OT #4 stated she attempted to complete an initial visit within 48 to 72 hours of receipt of the order from agency management. During continued interview, OT #4 stated she could not recall what day or whom from the agency administration informed her she had orders to evaluate and treat Patient #2. OT #4 stated she could not recall why she did not see Patient #2 until 6/20/23. During an interview on 8/2/23 at 1:48 p.m., the administrator stated she could not recall specifically why Patient #2 had a delayed start of care, but she vaguely remembered Patient #2 declining services when the agency originally reached out to schedule the start of care appointment. The administrator stated Patient #2's daughter-in-law reached out to the agency and also asked to be present during the start of care assessment as another possible reason Patient #2's start of care was delayed. The administrator acknowledged the agency failed to document why Patient #2's start of care was delayed and failed to notify and receive a delayed start of care order from Patient #2's PCP. 2. The clinical record for Patient #10 was reviewed on 8/1/23. The POC for the certification period dated 3/3/23 to 5/1/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders, signed by Patient #10's PCP on 3/28/23, included skilled nursing (SN) one time a week for one week and three as needed (PRN) visits based on the condition of the patient for assessment, patient education, pain management, obtain lab specimens PRN as ordered, compliance with medications, and anticoagulation monitoring; PT evaluation and treatment for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment for assessment and education regarding ADL and safety. a) The agency failed to complete a comprehensive assessment within 48 hours of receipt of the referral for Patient #10. Specifically, the agency completed the assessment four days after receipt of the referral. Review of the clinical record revealed referral documentation sent to the agency on 2/27/23 at 12:29 p.m. via fax from Patient #10's PCP ordering PT evaluation and treatment. On the top of this referral document was a handwritten note which stated disciplines RN, with SN #8's name on 3/1/23 next to her name, OT and PT written. Review of the POC for the certification period dated 3/3/23 to 5/1/23 revealed SN #8 had obtained a verbal order effective 3/3/23 for all POC orders including SN, OT and PT for Patient #10. Review of the clinical record revealed SN #8 completed a comprehensive assessment with Patient #10 on 3/3/23, four days after the agency received the referral. Record review failed to show a delayed start of care order for 3/3/23. Review of communication notes failed to show why Patient #10's start of care was delayed four days after the agency's receipt of the referral. During an interview on 8/2/23 at 8:16 a.m., SN #8 could not recall why she completed the start of care assessment with Patient #10 four days after the agency received the referral. SN #8 stated she was aware of the regulation for the agency to complete the start of care assessment within 48 hours of the agency receipt of the referral or the agency must request a delayed start of care order from the patient's physician. SN #8 acknowledged she failed to document why she completed Patient #10's start of care assessment four days after the agency received the referral. SN #8 stated she did not speak with Patient #10's PCP until 3/3/23 (four days after the referral) to receive verbal orders for SN, PT, OT and a delayed start of care. During an interview on 8/2/23 at 2:34 p.m., the administrator stated the handwritten note on Patient #10's 2/27/23 referral document which stated SN, PT and OT as disciplines to assess Patient #10 was the administrator's handwriting. The administrator stated Patient #10's wife requested SN and OT in addition to PT services and the administrator called Patient #10's PCP and received a verbal order to have all three disciplines assess Patient #10. The administrator acknowledged she failed to document this verbal order. Additionally, the administrator acknowledged SN #8 completed her start of care assessment late, the agency failed to document why this start of care assessment was not completed within 48 hours or receipt of the referral as required by regulation and failed to obtain a delayed start of care order in a timely manner. The administrator stated the agency's electronic medical record did not track much information, including when a referral was received compared to when the patient received their start of care assessment. Thus, the administrator tracked this information manually and struggled to keep track of all referrals and when start of care assessments were completed.

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 interview and record review, the agency failed to ensure an accurate comprehensive assessment was completed in 2 of 2 patients reviewed who had their comprehensive assessments completed by a therapist (Patients #2 and #10). Findings include: 1. The clinical record for Patient #2 was reviewed on 7/26/23. The plan of care (POC) for the certification period dated 6/16/23 to 8/14/23 revealed a start of care date of 6/20/23 (inaccurate certification dates- Cross reference G574); diagnosis included elevated white blood cell count and type two diabetes mellitus. Plan of care orders included physical therapy (PT) evaluation and treatment one to two times a week for eight weeks. a) The agency failed to ensure an accurate start of care comprehensive assessment was completed for Patient #2. Specifically, OT #4 failed to list all of Patient #2's diagnosis appropriate to this episode of care and failed to accurately assess Patient #2's integumentary system, sensory system, neurological system, nutritional needs, medication needs and durable medical equipment (DME). Review of Patient #2's initial comprehensive assessment completed by OT #4 showed OT #4 left the following sections blank: -sensory assessment; -neurological assessment (OT #4 documented Patient #2 was oriented to person, place and time, but failed to document if Patient #2 had issues with dizziness, spasticity, tremors, forgetful, headaches, rigidity, abnormal behavior, loss of sensation, lethargy, seizure precautions, neuromuscular weakness/loss or none of these problems identified); -medication status (OT #4 failed to complete a medication reconciliation as required for all patients who take prescription medication and receive home health care); and -DME. Review of the initial comprehensive assessment showed OT #4 inaccurately completed the diagnosis section of the assessment. Specifically, OT #4 documented Patient #2's primary diagnosis for the initiation of this home care episode was elevated white blood cell count and type two diabetes mellitus. OT #4 failed to document the diagnosis found on review of Patient #2's referral documentation of anemia, balance problems, chronic stage three kidney disease, hypertension, gait disturbance or generalized muscle weakness. Review of referral documentation sent to the agency on 6/13/23 by Patient #2's primary care physician (PCP) showed Patient #2 had a PCP visit completed on 4/27/23 and had the following diagnosis listed: leukocytosis, foot pain, anemia, balance problems, chronic stage three kidney disease, hypertension, type two diabetes mellitus and resolved sepsis and community acquired pneumonia. The 6/13/23 referral paperwork showed Patient #2 was referred for PT and OT evaluation and treatment due to gait disturbance and generalized muscle weakness. Review of a PT evaluation completed on 6/22/23 showed PT #9 documented Patient #2's medical diagnoses were type two diabetes mellitus and elevated white blood cell count. PT #9 documented Patient #2's PT diagnoses were gait instability and deconditioning. Review of the initial comprehensive assessment showed OT #4 inaccurately assessed Patient #2's integumentary system. OT #4 documented Patient #2 had no integumentary problems identified. Review of the PT evaluation completed on 6/22/23, two days after the OT completed the comprehensive assessment showed PT #9 documented Patient #2 had a recent right lower extremity skin tear and received care by the nursing staff at her assisted living facility. Further review of the initial comprehensive assessment revealed OT #4 failed to accurately assess Patient #2's nutrition needs. Specifically, in the nutritional approach section of the assessment, OT #4 identified Patient #2 as having no specific nutritional needs and documented Patient #2 was on a regular diet. OT #4 failed to assess Patient #2 was a diabetic. During a home visit on 7/27/23 at 10:30 a.m., Patient #2 stated she was a diabetic and her PCP recommended she follow a diabetic diet. Patient #2 stated she is noncompliant with this recommendation. During an interview on 8/1/23 at 11:47 a.m., OT #4 stated when she completed Patient #2's initial comprehensive assessment she observed her skin for bruises. Additionally, OT #4 asked Patient #2 if she had any issues with her skin or if she had fallen recently. OT #4 acknowledged she failed to complete a full head to toe assessment of Patient #2's skin so she was not aware Patient #2 had a right lower extremity skin tear. During continued interview, OT #4 stated when she assessed Patient #2's nutritional needs on 6/20/23 she asked Patient #2 if she had any specific diet she followed and Patient #2 denied having specific dietary recommendations, thus, OT #4 documented Patient #2 as having a regular diet and no specific nutritional approaches required. OT #4 stated she failed to ask Patient #2 if her PCP had recommended a diabetic diet to help control her diabetes. During an interview on 8/1/23 at 1:20 p.m., OT #4 stated the diagnosis for Patient #2's initial comprehensive assessment were already entered into the agency's electronic medical record (EMR) when OT #4 went to complete this section. OT #4 acknowledged the diagnosis should include all diagnoses a patient received care for. OT #4 stated she did not realize she had to add diagnoses to ensure a patient's comprehensive assessment was complete. During continued interview, OT #4 stated typically an agency registered nurse completed start of care assessments for patients and she had only completed a few start of care comprehensive assessments for patients. OT #4 stated she had limited training on how to complete a comprehensive assessment by the agency management team. 2. The clinical record for Patient #10 was reviewed on 8/1/23. The POC for the certification period dated 3/3/23 to 5/1/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders, signed by Patient #10's PCP on 3/28/23, included skilled nursing (SN) one time a week for one week and three as needed (PRN) visits based on the condition of the patient for assessment, patient education, pain management, obtain lab specimens PRN as ordered, compliance with medications, and anticoagulation monitoring; PT evaluation and treatment for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment for assessment and education regarding ADL and safety. Review of the POC for the certification period dated 5/2/23 to 6/30/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders included PT one to two times a week for eight weeks for assessment and education to improve safety and functional mobility independence. Further review of the POC for the certification period dated 5/2/23 to 6/30/23 revealed Patient #10 took 17 medications daily including the anticoagulant medication Eliquis 5 milligrams (mg) orally twice a day. a)The agency failed to ensure an accurate recertification comprehensive assessment was completed for Patient #10. Specifically, PT #9 failed to accurately assess Patient #10's hospitalization, failed to accurately identify Patient #10's sensory system; and failed to document Patient #10's DME and failed to identify Patient #10 took anticoagulation medication. Review of the start of care comprehensive assessment completed on 3/3/23 showed SN #8 assessed Patient #10 to be at risk for hospitalization for the following: history of falls, unintentional weight loss of a total of 10 pounds or more in the past 12 months, and currently taking five or more medications. SN #8 assessed Patient #10 to have a hearing impairment bilateral and abnormal vision with use of corrective lenses. SN #8 documented Patient #10 had a cane, elevated toilet seat, grab bars, a tub/shower bench, and a walker. SN #8 also assessed Patient #10 took the anticoagulant medication Eliquis 5 mg twice a day, was independent in administering this medication and exhibited no adverse reactions to the medication. Review of the recertification comprehensive assessment completed on 5/1/23 showed PT #9 documented Patient #10 had no increased risk for hospitalization. PT #9 failed to assess Patient #10 had a history of falls and unintentional weight loss and failed to identify Patient #10 took five or more medications. Review of the recertification comprehensive assessment completed on 5/1/23 showed PT #9 documented in his assessment of Patient #10's sensory system, Patient #10 was hearing impaired and wore bilateral hearing aides, but failed to identify Patient #10 had abnormal vision and wore glasses. Review of the recertification comprehensive assessment completed on 5/1/23 showed PT #9 failed to document DME for Patient #10. Review of the recertification comprehensive assessment completed on 5/1/23 showed PT #9 reconciled Patient #10's medications, but failed to identify Patient #10 took the anticoagulant medication, Eliquis 5 mg orally twice a day. During an interview on 8/1/23 at 12:45 p.m., PT #9 acknowledged the recertification comprehensive assessment he completed 5/1/23 for Patient #10 was inaccurate. PT #9 stated he was aware Patient #9 took the anticoagulation medication Eliquis, but he did not know how to fill the assessment form out correctly. PT #9 stated typically the agency had RNs complete comprehensive assessments and he only completed these assessments when a patient had no SN needs. PT #9 stated he had minimal training on how to complete comprehensive assessments and would benefit from continued training. 3. During an interview on 8/2/23 at 4:00 p.m., the administrator acknowledged Patients #2's and #10's comprehensive assessments completed by OT #4 and PT #9 respectively were inaccurate. The administrator stated prior to a few months ago, only SN completed start of care assessments. However, to reduce the SNs workload, the agency began having the OT and PTs complete the start of care comprehensive assessments. The administrator stated she educated OT #4 and PT #9 how to complete the start of care assessment, but acknowledged all members of her care team would benefit from re-education on how to accurately complete start of care assessments. The administrator stated, since her quality assurance (QA) nurse retired in February 2023, she had been responsible, with occasional assistance from the alternate administrator, for the QA tasks of the agency including reviewing comprehensive assessments for accuracy. The administrator acknowledged the agency's current QA process was not effective and the administrator planned to share some of these responsibilities with the alternate administrator and SN #14, as she understood the importance of having an accurate comprehensive assessment.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a complete comprehensive assessment was updated and revised, including the administration of the Outcome and Assessment Information Set (OASIS) within 48 hours of the patient's return home from a hospital admission of 24 hours or more, for 1 of 2 patients reviewed who had returned home following a hospitalization (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 7/26/23. The plan of care (POC) for the certification period 4/21/23 to 6/19/23 revealed a start of care date of 3/13/19; diagnosis included paraplegia, type two diabetes, neuromuscular dysfunction of bladder, fitting and adjustment of urinary device, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, hereditary factor VIII deficiency, hypothyroidism, fracture of right and left femurs. Plan of care orders included skilled nursing (SN) one to two times every two weeks for nine weeks depending upon the patient status for assessment, education, obtain lab specimens as ordered, change suprapubic catheter every two to three weeks as needed for occlusion, dislodgement, or malfunction of catheter; physical therapy (PT) evaluation and treatment one time a week for nine weeks for assessment and education to improve safety and functional mobility independence; occupational therapy (OT) evaluation and treatment one to two times per week for nine weeks for assessment and education regarding activities of daily living (ADLs) and safety; speech therapy (ST) evaluation and treatment (no further information provided on the POC for ST interventions); and home health aide (HHA) two times a week for nine weeks to provide assistance with personal care and ADLs. a) The agency failed to complete a comprehensive assessment within 48 hours for resumption of care following a hospitalization. Review of Patient #1's record revealed a HHA missed visit note on 6/1/23 completed by HHA #3 which stated the visit was missed due to Patient #1 being hospitalized. Review of Patient #1's record revealed a communication note written on 6/5/23 by SN #5 which stated Patient #1 fell out of bed, went to the hospital, was in the hospital for two days, and per family was then back home. During a home visit on 7/27/23 at 9:02 a.m., Patient #1's son confirmed Patient #1 fell out of bed on 6/1/23 when she tried to get up on her own and sustained fractures to both of her femurs. Patient #1's son stated at the time Patient #1 was suffering from a UTI, which made her confused and she forgot she needed help to get out of bed. Patient #1's son stated the fractures were inoperable and the hospital discharged Patient #1 home on 6/3/23. Patient #1's son stated on 6/6/23, Patient #1 was readmitted to the hospital for confusion and abnormal laboratory values and stayed in the hospital until she was discharged home on 6/11/23. Further clinical record review failed to show any hospital discharge paperwork, or if Patient #1 was considered observation status only or had been admitted for her 6/1/23 to 6/3/23 hospitalization stay for her fall from her bed resulting in her fracturing both of her femurs. Record review failed to show an OASIS/Transferred/Not Discharge assessment was completed for Patient #1's 6/1/23 hospitalization. Record review failed to show a resumption of care comprehensive assessment including completion of the OASIS was completed between 6/3/23 and 6/6/23. Review of an OASIS Transferred/Not Discharged assessment dated 6/6/23 revealed SN #5 documented Patient #1 used the hospital ER and was admitted to the hospital on 6/6/6/23. Review of a resumption of care assessment completed on 6/13/23 showed SN #5 documented Patient #1 recently discharged from the hospital due to falling out of bed and fracturing her bilateral femurs, as well as being treated for a urinary tract infection (UTI) and anemia. During an interview on 8/1/23 at 2:43 p.m., SN #5 stated she was aware of the regulation to complete a comprehensive assessment including the administration of the OASIS when a patient had a hospital stay of longer than 24 hours. SN #5 stated she was aware Patient #1 was hospitalized from 6/1/23 to 6/3/23 due to falling out of her bed and fracturing both of her femurs. SN #5 stated she did not complete a transfer OASIS for Patient #1's 6/1/23 hospitalization or a comprehensive assessment on 6/5/23 when she was made aware Patient #1 returned from the hospital per direction she received from either the administrator or the alternate administrator (she could not recall specifically who told her). SN #5 stated either the administrator or the alternate administrator advised her to write a communication note instead of completing a comprehensive assessment upon Patient #1's return home from the hospital. SN #5 stated she was told, since Patient #1 was only in the hospital a day or two, it was not necessary to complete an updated comprehensive assessment. During an interview on 8/2/23 at 3:50 p.m., the administrator acknowledged SN #5 had been advised to not complete a comprehensive assessment with Patient #1 upon her return home from the hospital on 6/3/23. The administrator stated an updated comprehensive assessment was not required if a patient only stayed in the hospital a day or two and/or if the patient was only in observation in the hospital. The administrator acknowledged Patient #1 sustained fractures to both of her femurs from her fall from bed on 6/1/23 and this was a significant change in Patient #1's health status, which would necessitate a SN complete an updated comprehensive assessment.

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 the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.60, CARE PLANNING, COORDINATION, QUALITY OF CARE was out of compliance. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. A total of 10 clinical records were reviewed for compliance with the Condition and Standards for Care Planning, Coordination and Quality of Care. Record review revealed a pattern of failures in regard to the establishment and implementation of patients' plans of care. Specifically, the agency failed to ensure each patient received home health services in accordance with a complete and accurate written plan of care established; to ensure services and treatments were provided in conformance with physician's orders; to ensure services and treatments were provided only as ordered by the physician; to ensure each patient's total plan of care was reviewed by the physician at least every 60 days; and failed to ensure coordination of care with physicians occurred and coordination of care amongst agency staff occurred to meet patient's needs. The following standard level deficiencies were also cited. G574- Standard: Plan of care must include the following - The agency failed to ensure each patient's plan of care included all medications, interventions, equipment, goals, and/or types of services and treatments. G578 - Standard: Conformance with Physician Orders- The agency failed to ensure services were provided in accordance with physician's orders. G580- Standard: Only as ordered by the physician - The agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician. G588 - Standard: Reviewed, revised by physician every 60 days - The agency failed to ensure each patient's total plan of care was reviewed by the physician at least every 60 days. G600 - Standard: Coordination of care - The agency failed to ensure communication with all physicians involved in the plan of care; failed to integrate orders to ensure the coordination of all services and interventions provided to the patient; and failed to coordinate care delivery to meet the patients needs.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure each patient's plan of care (POC) included all medications, interventions, equipment, goals, and/or types of services and treatments for 6 of 10 patients reviewed (Patients #1, #2, #6, #8, #9 and #10). Findings include: AGENCY POLICY According to an undated agency policy titled, Comprehensive Assessment Policy & Procedure/Care Plan Development & Review Process Policy & Procedure, (read in pertinent parts): "The physician orders are obtained at the Start of Care of patient services. There are periodic interim orders obtained from the physician between certifications which are sent for signature with any changes in Plan of Care. During the course of care, contact is made with the physician regarding changes in treatment and/or medications and there is follow up with appropriate interim orders. Every sixty days a complete review is performed for recertification and sent to the M.D." According to an undated agency policy titled, Significant Change in Patient Status Requiring a New Plan of Care, (read in pertinent parts): "Patient's Plan of Care, ordered and signed by physician, is normally for 60 days. -Medications that are added or changed within 60 days have an M.D. Order. -The Medication Profile in the computer is changed accordingly. -Changes such as Wound Care or Nutrition have a signed M.D. Order and the new procedures are documented in Progress Notes, then reflected in the next Plan of Care. -If there is a significant change in a patient's condition, there needs to be a new Plan of Care." 1. The clinical record for Patient #2 was reviewed on 7/26/23. The POC for the certification period dated 6/16/23 to 8/14/23 revealed a start of care date of 6/20/23; diagnosis included elevated white blood cell count and type two diabetes mellitus. Plan of care orders included physical therapy (PT) evaluation and treatment one to two times a week for eight weeks. a) Clinical record review revealed the agency failed to ensure Patient #2's plan of care included an accurate certification period. Review of the POC revealed the POC certification period was dated 6/16/23 to 8/14/23. Patient #2's start of care date was 6/20/23. There was no documentation to explain why Patient #2's certification period was dated four days before her start of care date. During an interview on 8/1/23 at 1:20 p.m., Occupational Therapist (OT) #4 acknowledged she completed the POC for the certification period dated 6/16/23 to 8/14/23 for Patient #2. OT #4 stated this section of the POC was already filled in for her by someone in the agency office. OT #4 confirmed she completed Patient #2's start of care visit on 6/20/23 and was the first discipline to see Patient #2 for this certification period. During an interview on 8/2/23 at 3:12 p.m., the administrator reviewed Patient #2's POC for the certification period dated 6/16/23 to 8/14/23 and agreed the certification period was inaccurate as Patient #2's start of care date was 6/20/23. The administrator could not state why the POC certification dates were inaccurately entered on the POC. b) Clinical record review revealed the agency failed to ensure Patient #2's POC included a complete diagnosis list. Review of referral documentation sent to the agency on 6/13/23 by Patient #2's primary care physician (PCP) showed Patient #2 had a PCP visit completed on 4/27/23 and had the following diagnosis listed: leukocytosis, foot pain, anemia, balance problems, chronic stage three kidney disease, hypertension, type two diabetes mellitus and resolved sepsis and community acquired pneumonia. The 6/13/23 referral paperwork showed Patient #2 was referred for PT and OT evaluation and treatment due to gait disturbance and generalized muscle weakness. Review of a PT evaluation completed on 6/22/23 showed PT #9 documented Patient #2's medical diagnoses were type two diabetes mellitus and elevated white blood cell count. PT #9 documented Patient #2's PT diagnoses were gait instability and deconditioning. Patient #2's POC failed to show the diagnosis of anemia, balance problems, chronic stage three kidney disease, hypertension, gait disturbance or generalized muscle weakness. During an interview on 8/1/23 at 1:20 p.m., OT #4 stated the diagnosis for Patient #2's POC were already entered into the agency's electronic medical record (EMR) when OT #4 went to complete this section of the POC. OT #4 acknowledged the diagnosis on a POC should include all diagnoses a patient received care for. OT #4 stated she did not realize she had to add diagnoses to ensure a patient's POC was complete. During an interview on 8/2/23 at 3:07 p.m., the administrator stated Administrative Assistant #11 entered the first two diagnoses into the agency's EMR, but the clinician completing the POC was to add any other diagnosis that pertained to the care of the patient on the POC. The administrator acknowledged OT #4 failed to add all diagnoses Patient #2 received care for to her POC. c) Clinical record review revealed the agency failed to ensure Patient #2's POC included a complete medication list. Review of Patient #2's medication list from her referral paperwork sent to the agency on 6/13/23 revealed as of a 4/27/23 PCP visit, Patient #2 was taking the following medications: -Acitretin 10 milligrams (mg) oral capsule; -Atorvastatin Calcium 20 mg oral tablet take one tablet by mouth every night at bedtime; -Azithromycin 250 mg oral tablet; -Bayer contour Normal LIQD (a solution designed to check the accuracy of glucose meter and test strips); -Bayer Contour Test Strips; -Cefdinir 300 mg oral capsule; -Gabapentin 300 mg oral capsule take one capsule three times daily; -Hydrochlorothiazide 25 mg oral capsule take one tablet by mouth daily; -Levothyroxine Sodium 88 micrograms (mcg) oral tablet take one tablet by mouth daily; -Lidocaine 5% external patch, apply one patch to the affected area and leave in place for 12 hours then remove the patch and leave it off for 12 hours: -Lisinopril 10 mg oral tablet take one tablet by mouth daily; -Metformin HCI extended release (ER) 750 mg oral tablet extended release 24 hour, take one tablet by mouth twice daily; -Polymyxin B-Trimethoprim 10000-0.1 unit/ml-% ophthalmic solution, instill two drops into both eyes three times daily; and -Triamcinolone Acetonide 0.1% external cream. During a home visit on 7/27/23 at 10:31 a.m., Patient #2 stated she took a long list of medications and her son helped her manage medications including setting up a weekly pill box for her. During an interview on 8/1/23 at 12:15 p.m., Patient #2's son stated Patient #2 took the following medications: -Acitretin 10 mg, stated she had stopped the medication for awhile but was told to restart recently; --Atorvastatin Calcium 20 mg oral tablet take one tablet by mouth every night at bedtime; -Azithromycin 250 mg oral tablet; -Cefdinir 300 mg oral capsule; -Hydrochlorothiazide 25 mg oral capsule take one tablet by mouth daily; -Levothyroxine Sodium 88 mcg oral tablet take one tablet by mouth daily; -Lisinopril 10 mg oral tablet take one tablet by mouth daily; and -Metformin HCI extended release (ER) 750 mg oral tablet extended release 24 hour, take one tablet by mouth twice daily. Patient #2's son stated Patient #2 was no longer taking the Gabapentin, Polymyxin B-Trimethoprim eye drops and no longer needed or used the Lidocaine patch or the Triamcinolone Acetonide external cream. He could not recall the exact date she stopped using these four medications. Review of the medication list on Patient #2's POC for the certification period dated 6/16/23 to 8/14/23 revealed the following list: -Metformin 750 mg one time a day by mouth; -Atorvastatin 20 mg one time a day by mouth; -Levothyroxine 88 mg one time a day by mouth; and -Lisinopril 10 mg one time a day by mouth. Patient #2's POC failed to list all medications she took including: Acitretin, Azithromycin, Cefdinir, Hydrochlorothiazide, and the Bayer Contour testing solution and test strips available for Patient #2's glucometer. During an interview on 8/1/23 at 11:54 a.m., OT #4 stated she used a medication list provided to her by Patient #2 during her start of care assessment to document the medications Patient #2 took. OT #4 stated she could not find a SN at Patient #2's assisted living facility (ALF) to verify Patient #2's medication list. OT #4 also stated she was not aware of the referral paperwork for Patient #2 the agency had in the agency's EMR which included a medication list. d) Clinical record review revealed the agency failed to ensure Patient #2's POC included a list of durable medical equipment (DME) and supplies used by Patient #2. Review of the POC for the certification period dated 6/16/23 to 8/14/23 failed to show documentation of DME and supplies used by Patient #2. Review of the PT evaluation completed on 6/22/23 showed PT #9 documented Patient #2's DME as follows: a four wheeled walker, grab bars, a bath bench, and a raised toilet seat. During a home visit on 7/27/23 at 10:30 a.m. Patient #2 was observed to have a four wheel walker. Patient #2 stated she had grab bars in her bathroom and owned a glucometer. During an interview on 8/1/23 at 11:57 a.m., OT #4 stated she recalled Patient #2 had a four wheeled walker and a bath bench. OT #4 was surprised she did not complete the section on DME and supplies on Patient #2's POC. e) Clinical record review revealed the agency failed to ensure Patient #2's POC listed accurate vital sign parameters on when to notify Patient #2's PCP. Review of POC for the certification period dated 6/16/23 to 8/14/23 showed the agency was to notify Patient #2's PCP when her heart rate was above 70 beats per minute and her oxygen saturation (SPO2) level was below 95%. During an interview on 8/1/23 at 11:58 a.m., OT #4 stated she did not understand what vital sign parameters on the POC meant so she documented the heart rate and SPO2 she obtained when she assessed Patient #2's vitals during her start of care visit on 6/20/23. OT #4 stated she did not call Patient #2's PCP or obtain written vital sign parameters for Patient #2's PCP and stated the vital sign parameters on the POC were inaccurate. f) Clinical record review revealed the agency failed to ensure Patient #2's POC included all goals and interventions for Patient #2. Review of the PT POC written on 6/22/23 showed PT #9 documented Patient #2's PT long term goals, to be accomplished in four weeks, as follows: -Improve bilateral lower extremity strength to four fifths to improve transfers, balance, strength, safety and stability; -Improve Patient #2's Tinnetti score to 21 of 28 to reflect improved transfers, standing and gait safety and stability; -Patient #2 to be independent and complaint with an advanced home exercise program; and -Patient #2 will demonstrate 100 % awareness of fall prevention and safety. PT #9 documented he would use the following interventions with Patient #2: therapeutic exercise, balance training, gait training, transfer training, functional mobility training, proprioceptive training, relaxation techniques, postural control training, teaching safe and effective use of adaptive/assistive device, teaching fall prevention/safety, establishing/upgrading a home exercise program, teach energy conservation techniques, pulse oximetry as needed (PRN), and patient/caregiver education/training. Review of the POC for the certification period dated 6/16/23 to 8/14/23 stated goals for Patient #2 to see Patient #2's PT evaluation. The POC failed to state goals for Patient #2. Further review of the POC showed interventions included the following: the PT assessed the patient and developed a plan of care with patient/caregiver involvement to be countersigned by a physician and the PT was to notify a physician immediately of any potential problems that impeded completion of patient recovery and desired goals. The POC failed to state any further interventions the PT would use with Patient #2. During an interview on 8/1/23 at 1:15 p.m., OT #4 stated she was the only discipline who had completed their evaluation when she completed the POC for Patient #2. OT #4 stated she had no OT goals or interventions for Patient #2 as Patient #2 had declined further OT services. OT #4 stated she did not know the PT goals or interventions, thus she did not include those goals or interventions on the POC. OT #4 also stated she was unaware as the clinician who opened Patient #2's home health care episode, it was her responsibility to include all goals and interventions for all clinicians who worked with Patient #2 from the agency would have/use with Patient #2 on the POC. h) During an interview on 8/1/23 at 11:24 a.m., OT #4 stated she did not normally complete the start of care visits with patients or complete the agency POC for the patient. During an interview on 8/1/23 at 1:15 p.m., OT #4 stated she would benefit from more training on how to complete start of care comprehensive assessments and POCs for patients. During an interview on 8/2/23 at 3:09 p.m., the administrator stated OT #4 failed to ensure Patient #2's POC had all required items per regulation. The administrator stated the agency recently started to delegate starts of care to the OTs and PTs and the POC for Patient #2 was one of the first POCs OT #4 had completed. 2. The clinical record for Patient #1 was reviewed on 7/26/23. The POC for the certification period 4/21/23 to 6/19/23 revealed a start of care date of 3/13/19; diagnosis included paraplegia, type two diabetes, neuromuscular dysfunction of bladder, fitting and adjustment of urinary device, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, hereditary factor VIII deficiency, hypothyroidism, fracture of right and left femurs. Plan of care orders included skilled nursing (SN) one to two times every two weeks for nine weeks depending upon the patient status for assessment, education, obtain lab specimens as ordered, change suprapubic catheter every two to three weeks as needed for occlusion, dislodgement, or malfunction of catheter; PT evaluation and treatment one time a week for nine weeks for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment one to two times per week for nine weeks for assessment and education regarding ADLs and safety; speech therapy (ST) evaluation and treatment (no further information provided on the POC for ST interventions); and home health aide (HHA) two times a week for nine weeks to provide assistance with personal care and ADLs. a) Clinical record review revealed the agency failed to ensure Patient #1's POC included orders for catheter irrigation. Review of SN notes revealed on 5/2/23 SN #5 documented she irrigated Patient #1's suprapubic catheter (a tube inserted through a patient's abdomen directly to their bladder to drain urine) with 60 ml of sterile water and "instructed on irrigating catheter - as patient has a lot of sediment." Review of the POC for the certification dated 4/21/23 to 6/19/23 showed the agency SN was to use an aseptic technique to insert a 22 french catheter with a 10 cc balloon to a gravity drainage system every two to three weeks and as needed for occlusion, dislodgement, or malfunction of the catheter. Additionally, the SN was to instruct the patient/caregiver on indwelling catheter self-management including signs and symptoms of complications to report, infection control, perineal care, tube and bag placement. There was no evidence to show SN was ordered to perform catheter irrigation with Patient #1. Review of interim orders for Patient #1 from 4/21/23 to 6/19/23 failed to show an interim order for SN to perform catheter irrigation. During an interview on 8/1/23 at 2:33 p.m., SN #5 stated she had a standing order for catheter irrigation on her POC from Patient #1's primary care physician (PCP). SN #5 reviewed the POC for the certification dates 4/21/23 to 6/19/23 and acknowledged she failed to document the standing order she had from Patient #1's PCP. SN #5 stated she must have forgotten to add this order to Patient #1's POC. SN #5 stated she instructed Patient #1's son on how to irrigate Patient #1's catheter. b) Clinical record review revealed the agency failed to ensure Patient #1's POC included a complete list of DME and supplies. Review of the POC for the certification periods 4/21/23 to 6/19/23 and 6/20/23 to 8/18/23 showed SN #5 documented for both certification periods, Patient #1 had the following DME: wheelchair, oxygen, and hospital bed. Review of a PT evaluation completed on 6/21/23 showed PT #9 documented Patient #1 had the following DME equipment: a wheelchair, hospital bed and a Hoyer lift (a mechanical device used to assist a person to move from one surface to another). During a home visit conducted on 7/27/23 at 9:02 a.m., Patient #1 was observed to have a hospital bed with an air mattress, a trapeze (a triangular device attached to a patient's hospital bed which assists a patient with moving in bed and getting in and out of bed), supplemental oxygen, and a suprapubic catheter. Patient #1, her son and son-in-law also stated Patient #1 had a Hoyer lift, an electric wheelchair, and a glucometer. There was no documentation on the POC for either certification period of Patient #1's Hoyer lift, trapeze, air mattress, glucometer, or supplies for changing Patient #1's suprapubic catheter. During an interview on 8/1/23 at 2:40 p.m., SN #5 stated she used documentation from a patient's referral to document what DME a patient had on their POC. SN #5 acknowledged Patient #1's two POCs for certification periods reviewed were missing DME Patient #1 used and SN #5 stated she did not realize it was important to document an accurate list of DME used by each patient on their POC. c) Clinical record review revealed the agency failed to ensure Patient #1's POC included a list of fracture precautions agency personnel were to follow after Patient #1 sustained bilateral femur fractures from a fall out of bed on 6/1/23. Review of Patient #1's record revealed a HHA missed visit note on 6/1/23 completed by HHA #3 which stated the visit was missed due to Patient #1 being hospitalized. Review of Patient #1's record revealed a communication note written on 6/5/23 by SN #5 which stated Patient #1 fell out of bed, went to the hospital, was in the hospital for two days, and per family was then back home. Review of a resumption of care assessment completed on 6/13/23 showed SN #5 documented Patient #1 recently discharged from the hospital due to falling out of bed and fracturing her bilateral femurs, as well as being treated for a urinary tract infection (UTI) and anemia. Review of the POC for the certification periods 4/21/23 to 6/19/23 and 6/20/23 to 8/18/23 showed SN was to teach on fracture precautions, but failed to specify what the fracture precautions were or who the SN was to teach these precautions too. During a home visit on 7/27/23 at 9:02 a.m., Patient #1's son confirmed Patient #1 fell out of bed on 6/1/23 when she tried to get up on her own and sustained fractures to both of her femurs. Patient #1's son stated Patient #1 was suffering from a UTI at the time which made her confused and she forgot she needed help to get out of bed. Patient #1's son stated the fractures were inoperable and the hospital discharged Patient #1 home on 6/3/23. Patient #1's son could not recall any specific precautions Patient #1 had to follow as Patient #1 was non-weight bearing due to her paralysis. During an interview on 8/1/23 at 2:45 p.m., SN #5 stated she added SN to teach fracture precautions to Patient #1's POC certification periods to indicate to be careful as Patient #1 had two new fractured femurs from her fall from her bed on 6/1/23. SN #5 stated she did not speak with Patient #1's PCP or the orthopedist who cared for Patient #1 in the hospital from 6/1/23 to 6/3/23 to receive specific instructions on what precautions the agency clinicians and her family should follow to assist her bilateral femur fractures to heal. 3. The clinical record for Patient #6 was reviewed on 7/27/23. The POC for the certification periods dated 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23 revealed a start of care date of 10/6/21; diagnosis included leukemia, HTN and drug-induced polyneuropathy. The POC orders included SN one to six times per week every two weeks depending on the patient status/chemotherapy rounds (no duration was provided) for assessment, patient education, lab collection PRN/ordered, foot and nail care, compliance with medication, administration of subcutaneous injection of Cytarabine 30 mg (chemotherapy medication) under skin daily on days one through seven of each 28 day cycle, daughter to administer medication on the weekends. a) Clinical record review revealed the agency failed to ensure Patient #6's POC included duration for SN services. Review of the POCs for the certification periods 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23 showed SN services were ordered for one to six times per week every two weeks. The SN order failed to state for how many weeks SN was to provide care. During an interview on 8/1/23 at 3:04 p.m., SN #5 stated the duration for SN services for Patient #6 should have been documented as nine weeks. SN #5 stated she forgot to add the duration for her SN order for both certification periods. b) Clinical record review revealed the agency failed to ensure Patient #6's POCs included an accurate medication list. Review of the medication list for the POCs for the certification periods of 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23 showed SN #5 documented twice Patient #6 was to take Venclexta 100 mg oral tablet one tablet daily for seven days. During an interview on 8/1/23 at 3:03 p.m., SN #5 acknowledged she accidently had Venclexta listed twice on the POCs for both certification periods reviewed. SN #5 stated when she entered education on the medication profile in the clinical record, the entry sometimes populated twice and she forgot to remove the duplicate entry. c) Clinical record review revealed the agency failed to ensure Patient #6's POCs contained accurate intervention frequency and duration instructions for Patient #6's Cytarabine (subcutaneous injectable medication used in the management and treatment of leukemia) medication. Review of SN notes from 4/17/23 to 7/26/23 showed SNs #5 and #8 documented they administered Cytarabine injections to Patient #6 from 4/24/23 to 4/28/23. Six weeks later SN #5 and #8 documented they administered Cytarabine injections to Patient #6 from 6/5/23 to 6/8/23. Six weeks later SN #5 and #8 documented they administered Cytarabine injections to Patient #6 from 7/20/23 to 7/26/23. Review of POCs for the certification periods 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23, completed by SN #5, showed on the medication list, Patient #6 was to receive Cytarabine 20 mg/ml, inject 30 mg (1.5 ml) under his skin once daily on days one to seven of each four to six week cycle, with the frequency and duration varying depending upon when Patient #6 saw his oncologist and what was ordered. In the interventions, the following was documented: "using aseptic technique, SN to perform/teach caregiver/patient to perform subcutaneous injection of Cytarabine 20 mg/ml injectable solution 30 mg (1.5ml) inject 30 mg (1.5 ml) under skin once daily on days one to seven of each 28 day cycle subcutaneous (SQ) - daughter to administer injections on the weekends." SN #5 failed to update Patient #6's interventions for Cytarabine to reflect he received this medication every four to six weeks as documented in his medication list versus every 28 days as documented on his intervention for Cytarabine injections. During an interview on 8/1/23 at 3:05 p.m., SN #5 stated when Patient #6 started home health care, the duration between his Cytarabine injections was every 28 days or four weeks. SN #5 stated Patient #6's oncologist had lengthened the time between his Cytarabine injections to be as long as every six weeks, including for the last three cycles between April 2023 and July 2023. SN #5 stated she remembered to update Patient #6's medication list to reflect this change in duration between Cytarabine injections for Patient #6 but forgot to update the intervention for this medication on his POCs reviewed. 4. The clinical record for Patient #10 was reviewed on 8/1/23. The POC for the certification period dated 3/3/23 to 5/1/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders included SN one time a week for one week and three PRN visits based on the condition of the patient for assessment, patient education, pain management, obtain lab specimens PRN as ordered, compliance with medications, and anticoagulation monitoring; PT evaluation and treatment for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment for assessment and education regarding ADL and safety. Review of the POC for the certification period dated 5/2/23 to 6/30/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders included PT one to two times a week for eight weeks for assessment and education to improve safety and functional mobility independence. a) Clinical record review showed the agency failed to ensure accurate interventions were listed on the POC. Review of SN notes for Patient #10 from 3/3/23 to his discharge from the agency on 6/2/23 showed Patient #10 received one SN visit on 3/3/23. Review of the POC for the certification period dated 5/2/23 to 6/30/23 showed PT #9 included PT interventions and goals and the following SN interventions: assessment and training to manage and mitigate pain; education on new and/or changed medications; medication review and reconcile medications as indicated; educate patient/caregiver on anticoagulation monitoring and intervene to prevent complications; and assessment, identify and mitigate risk factors, and educate to prevent falls/injuries. PT #9 failed to remove the SN interventions from the POC when SN no longer provided care to Patient #9. During an interview on 8/2/23 at 8:50 a.m., SN #8 confirmed she provided Patient #10 with one SN visit on 3/3/23 for his start of care assessment. SN #8 stated she asked for three PRN SN visits on the POC for the certification period dated 3/3/23 to 5/1/23 in case a SN need arose during the certification period. SN #8 stated Patient #10's primary reason for his home health care episode from 3/3/23 to 6/2/23 was for PT assessment and treatment. SN #8 stated she lost track of Patient #10 and forgot to discharge Patient #10 at the end of the certification period 3/3/23 to 5/1/23. (Cross Reference G600) During an interview on 8/2/23 at 9:55 a.m., PT #9 stated he recently began to complete start of care and recertification comprehensive assessments and POCs. PT #9 stated the agency provided him with minimal training on how to perform these assessments and complete the POCs. PT #9 stated he forgot to remove all of the SN interventions from Patient #10's POC for the certification period 5/2/23 to 6/30/23. b) Clinical record review revealed the agency failed to ensure Patient #10's POC included a complete list of DME and supplies. Review of the POC for the certification period 3/3/23 to 5/1/23 showed the following DME and supplies documented: cane, walker, tub/shower bench, grab bars, elevated toilet seat. Review of the PT POCs for 3/13/23, 4/28/23, and 6/2/23 showed the following DME documented: single point cane, grab bars and bath bench. Review of the POC for the certification period 5/2/23 to 6/30/23 failed to have any DME or supplies documented. During an interview on 8/1/23 at 12:25 p.m., PT #9 stated the DME and supplies section of the POC was auto populated from the recertification comprehensive assessment created in the agency's EMR and due to PT #9's lack of knowledge on how to fill out the recertification comprehensive assessment, he failed to have DME and supplies listed for Patient #10 on the POC for the certification period dated 5/2/23 to 6/30/23. 5. The clinical record for Patient #8 was reviewed on 7/31/23. The POC for the certification period dated 5/27/23 to 7/25/25 revealed a start of care date of 3/28/23; diagnosis included dementia, laceration to lower leg, polyarthritis, joint disorder, hypothyroidism, Vitamin B deficiency, muscle weakness and abnormalities of gait and mobility. The POC orders included SN one to three times a week for four weeks then one to two times a week every two weeks for 60 days based on the condition of the patient for assessment, patient education, obtain lab specimens PRN as ordered, compliance with medications, and wound care. a) Clinical record review revealed the agency failed to ensure Patient #8's wound care orders contained a frequency. Review of POC for the certification period 5/27/23 to 7/25/23 for Patient #8 showed SN #8 documented a wound care intervention as follows: "SN to perform wound care to bilateral anterior lower tibia dermal tears. Cleanse wounds with normal saline or wound cleanser, pat dry; apply non stick dressing, cover with ABDs (non-woven thick and absorbent wound care dressing), wrap with conform gauze and secure with tape, using aseptic technique. Apply tubi grip (a elasticated tubular bandage that provides firm support) to bilateral lower extremity toes to knees." The intervention failed to list how often SN was to perform wound care for Patient #8. Review of SN notes from 5/29/23 to Patient #8's discharge on 7/3/23 showed SN #8 documented she completed wound care to Patient #8's bilateral lower extremities on 5/29/23 and 6/1/23. SN #8 documented on 6/6/23 she completed wound care to Patient #8's right lower extremity as ordered and cleansed Patient #8's left lower tibia wound and left it open to air. On 6/13/23, SN #8 documented both anterior tibial wounds were healed and no longer required wound care. During an interview on 8/2/23 at 8:16 a.m., SN #8 stated she provided wound care to Patient #8's bilateral lower extremities at every SN visit until wound care was discharged on Patient #8's left lower extremity on 6/6/23 and her right lower extremity on 6/13/23. SN #8 acknowledged due to her variable frequency order for SN visits of one to three times a week for four weeks and then one to two times a week every two weeks, her wound care intervention should have clarified how often wound care was to be performed. 6. The clinical record for Patient #9 was reviewed on 7/27/23. The POC for the certification periods dated 3/3/23 to 5/1/23 and 5/2/23 to 6/30/23 revealed a start of care date of 7/29/23 (inaccurate start date); diagnosis included neuromuscular dysfunction of bladder, cerebral infarction, peripheral vascular diseases, polyneuropathy, mild cognitive impairment and heart disease. The POC orders included SN one to two times per two weeks for nine weeks for catheter changes, symptom management and ongoing assessment. a) Clinical record review showed the agency failed to ensure an accurate start of care date was listed on Patient #9's POCs. Review of the POC for the certification period dated 3/3/23 to 5/1/23 showed SN #5 documented Patient #9's start of care date was 7/29/23, 149 days after the start of the certification period. Review of the POC for the certification period dated 5/2/30 to 6/30/23 showed SN #5 documented Patient #9's start of care date was 7/29/23, 89 days after the start of the certification period. During an interview on 8/2/23 at 3:13 p.m., the administrator acknowledged the start of care date for Patient #9 was inaccurate on both POCs reviewed. The administrator stated she did not know how this was missed in the agency quality assurance review process. 7. During an interview on 7/26/2323 at 10:16 a.m., the administrator stated she and the alternate administrator were responsible for reviewing agency paperwork for accuracy/quality assurance (QA). The administrator stated the agency had another SN who primarily completed the review of documentation for accuracy, but she retired a few months ago. During an interview on 8/2/23 at 1:15 p.m., the administrator acknowledged Patients #1, #2, #6, #8, #9 and #10 POCs were inaccurate. The administrator stated prior to a few months ago, only SN completed start of care assessments and POC for patients. However, to reduce the SNs workload, the agency began having the OT and PTs complete the start of care assessments. The administrator stated she educated OT #4 and PT #9 how to complete the start of care assessment and corresponding agency POC, but acknowledged all members of her care team would benefit from re-education on how to accurately complete and document a POC. The administrator stated since her QA nurse retired in February 2023, she had been responsible, with occasional assistance from the alternate administrator, for the QA tasks of the agency including reviewing POCs for accuracy prior to sending the POCs to a patient's physician for review and signature. The administrator acknowledged the agency's current QA process was not effective and the administrator planned to share some of these responsibilities more with the alternate administrator and SN #14 as she understood the importance of having an accurate and complete POC for each patient for each certification period.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure services were provided in accordance with physician's orders for 5 of 10 patients reviewed (Patients #1, #5, #6, #7 and #10). Findings include: AGENCY POLICY According to an undated agency policy titled, Comprehensive Assessment Policy & Procedure/Care Plan Development & Review Process Policy & Procedure, (read in pertinent parts): "The physician orders are obtained at the Start of Care of patient services. There are periodic interim orders obtained from the physician between certifications which are sent for signature with any changes in Plan of Care. During the course of care, contact is made with the physician regarding changes in treatment and/or medications and there is follow up with appropriate interim orders." According to an undated agency policy titled, Initial Therapy Visit Policy, (read in pertinent parts): "Upon receipt of referral from physician, therapist has (5) days to do initial evaluation if therapy is ordered in conjunction with nursing." 1. The clinical record for Patient #1 was reviewed on 7/26/23. The plan of care (POC) for the certification period 4/21/23 to 6/19/23 revealed a start of care date of 3/13/19; diagnosis included paraplegia, type two diabetes, neuromuscular dysfunction of bladder, fitting and adjustment of urinary device, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, hereditary factor VIII deficiency, hypothyroidism, fracture of right and left femurs. Plan of care orders included skilled nursing (SN) one to two times every two weeks for nine weeks depending upon the patient status for assessment, education, obtain lab specimens as ordered, change suprapubic catheter every two to three weeks as needed for occlusion, dislodgement, or malfunction of catheter; physical therapy (PT) evaluation and treatment one time a week for nine weeks for assessment and education to improve safety and functional mobility independence; occupational therapy (OT) evaluation and treatment one to two times per week for nine weeks for assessment and education regarding activities of daily living (ADL) and safety; speech therapy (ST) evaluation and treatment (no further information provided on the POC for ST interventions); and home health aide (HHA) two times a week for nine weeks to provide assistance with personal care and ADLs. Review of Patient #1's clinical record revealed Patient #1 was hospitalized from 6/6/23 to 6/11/23 due to acute toxic versus metabolic encephalopathy (altered brain function) and moderate protein calorie malnutrition. Upon Patient #1's discharge from the hospital on 6/11/23, the doctor at the hospital ordered resumption of home health services to include SN, HHA, PT and OT. a) The agency failed to ensure PT visits were completed as ordered. Review of Patient #1's clinical record revealed PT #9 conducted a PT evaluation on 6/21/23, eleven days after PT was ordered upon Patient #1's discharge from the hospital and nine days after SN #5 completed a resumption of care assessment for Patient #1. There was no documentation as to why the PT evaluation was not completed timely. Additionally, the agency failed to follow their own policy to complete the PT evaluation within five days of the resumption of care assessment. During an interview on 8/1/23 at 12:25 p.m., PT #9 stated once he received orders for evaluation and treatment, the agency expected he would complete the visit with the patient referred within 48 hours. PT #9 stated he was texted by the alternate administrator on 6/13/23 regarding PT evaluation and treat orders for Patient #1 and he could not recall why he did not complete the visit until 6/21/23, nine days after he was notified. b) The agency failed to ensure OT visits were completed as ordered. Review of Patient #1's clinical record from 6/11/23 to 6/19/23 showed no evidence an OT had completed an evaluation or conducted any visits as instructed on the POC. Review of the plan of care for the certification period 6/20/23 to 8/18/23 revealed an order for OT evaluation and treatment for one to two times a week for nine weeks. Review of the clinical record failed to show an OT evaluation or any follow up visits were conducted between 6/20/23 and 7/31/23. Review of Patient #1's clinical record revealed OT #4 conducted an OT evaluation on 8/1/23, 52 days after OT was ordered upon Patient #1's discharge from the hospital and 50 days after SN #5 completed a resumption of care assessment for Patient #1. There was no documentation as to why the OT evaluation was not completed timely. Additionally, the agency failed to follow their own policy to complete the OT evaluation within five days of a resumption of care assessment. During a home visit on 7/27/23 at 9:02 a.m., Patient #1's son-in-law confirmed OT had yet to complete an evaluation on Patient #1 and was scheduled to come 8/1/23. Patient #1's son-in-law stated the OT had attempted to call a couple times to schedule her evaluation and struggled to find a time to schedule her visit in part due to Patient #1's rehospitalization from 6/22/23 to 6/27/23 and the OT informing Patient #1's son-in-law she had difficulty reaching Patient #1's son and son-in-law to schedule the visit. During an interview on 8/1/23 at 11:21 a.m., OT #4 confirmed she was completing Patient #1's OT evaluation at 12:00 p.m. on 8/1/23, 52 days after OT evaluation and treat orders were received by the agency and 50 days after SN #5 completed her resumption of care assessment. OT #4 stated when she received the order for OT evaluation and treatment (she could not recall what day she received the order) she scheduled the visit, but Patient #1 went back to the hospital from 6/22/23 to 6/27/23, so OT #4 was unable to complete the visit as scheduled. OT #4 stated she waited for SN #5 to inform her Patient #1 had returned from the hospital and then she attempted to reschedule her evaluation visit with Patient #1's family. OT #4 stated she called on two different occasions and Patient #1's son-in-law accidentally hung up on her trying to transfer the phone call to Patient #1's son. The OT called a third time and was able to schedule her evaluation visit for 8/1/23. OT #4 acknowledged she failed to document any of her attempts to schedule her evaluation visit with Patient #1 or her communication with SN #5 regarding Patient #1 returning from the hospital. OT #4 stated the agency expectation was she would complete evaluations within 48 to 72 hours upon receiving the order. OT #4 stated she was not aware of the regulation to inform a patient's doctor if there was a delay in her ability to complete evaluation orders in a timely manner. c) The agency failed to ensure ST visits were completed as ordered. Review of Patient #1's supplemental orders revealed a verbal order for ST to evaluate and treat written by SN #5 on 6/13/23 and signed by Patient #1's doctor on 6/22/23. Review of Patient #1's clinical record from 6/13/23 to 6/19/23 failed to show a ST evaluation was completed as ordered on 6/13/23. Review of the plan of care for the certification period 6/20/23 to 8/18/23 revealed orders for ST evaluation and treatment. Review of the clinical record failed to show an ST evaluation was conducted between 6/20/23 and 8/2/23. Review of Patient #1's clinical record failed to show a ST evaluation was completed as ordered. There was no documentation as to why the ST evaluation was not completed timely. Additionally, the agency failed to follow their own policy to complete the ST evaluation within five days of a resumption of care assessment. During a home visit on 7/27/23 at 9:02 a.m., Patient #1's son stated Patient #1 nor her son received a phone call from anyone in the agency to schedule a ST evaluation and Patient #1 had not received a ST evaluation from 6/13/23 to 7/27/23. During an interview on 8/1/23 at 12:04 p.m., ST #6 (the agency's only ST) stated she did not recall being informed of ST orders for Patient #1 and confirmed she had not scheduled or completed a ST evaluation for Patient #1 as ordered on 6/13/23. During an interview on 8/2/23 at 1:34 p.m, the administrator stated ST evaluation and treatment was ordered due to Patient #1 struggling to eat. The administrator stated after the ST evaluation and treatment verbal order was received by SN #5, SN #5 informed the administrator Patient #1's struggle to eat was resolved by a dentist and a ST evaluation was no longer necessary. The administrator also stated Patient #1 lived out of the geographical region served by ST #4. When the agency received ST orders out of the geographical region served by ST #4, the agency would refer the patient to another home health care agency for ST. The administrator acknowledged Patient #1's clinical record failed to have documentation of the reason for the ST evaluation, communication with the ST regarding this order, the reason a ST evaluation was no longer necessary, a discharge order for ST, or if the family was informed of another home health care agency who could assist Patient #1 with her ST needs. 2. The clinical record for Patient #5 was reviewed on 7/26/23. The POC for the certification period dated 6/5/23 to 8/3/23 revealed a start of care date of 6/5/23; diagnosis included unspecified open wounds on the right and left leg, repeated falls, degenerative disease of the nervous system, osteoarthritis, hypertension, major depressive disorder, osteoporosis, immunodeficiency, cachexia, and other abnormalities of gait and mobility. The POC orders included SN one to two times per week for nine weeks depending upon patient condition for assessment, patient education, lab collection as needed (PRN)/ordered, compliance with medication, and wound care; PT evaluation and treat one time a week for nine weeks for assessment, gait training, education on safety precautions, pain management, strengthening/conditioning exercises, balance/coordination training, and transfer training; OT evaluation and treat one time a week for nine weeks for assessment, ADL training, safety precautions, pain management, and strengthening/conditioning exercises; and HHA two times a week for nine weeks for assistance with personal care and ADLs. a) The agency failed to ensure SN visits were provided as ordered. A review of SN visit notes from 6/5/23 to 7/24/23 failed to show a SN visit was completed the week of 6/25/23 to 7/1/23, a total of one missed SN visit for Patient #5. Review of the clinical record failed to show any documentation as to the reason for the missed visits or how the SN needs for Patient #5 were met during that time. During an interview on 8/1/23 at 1:45 p.m., SN #5 stated she was the SN assigned to care for Patient #5. SN #5 acknowledged she missed the two SN visits for Patient #5. SN #5 stated for one of the two missed visits (she could not recall which week), Patient #5 asked SN #5, due to a schedule conflict, to change the scheduled SN visit time from a Monday to a Thursday. SN #5 informed Patient #5, due to other obligations she could not change the scheduled SN visit from Monday to Thursday. SN #5 stated she offered to check with the other two SNs who worked at the agency to see if either of them could see Patient #5 during the requested time, but Patient #5 declined this offer and chose to cancel the visit instead. SN #5 acknowledged she failed to: document this conversation in Patient #5's clinical record; write a missed visit notification in Patient #5's clinical record, or to inform Patient #5's doctor of the missed visit. During continued interview, SN #5 stated she could not recall exactly why the other SN visit was not completed as ordered, but she thought it was due to Patient #5 canceling due to having a doctor's visit scheduled at the same time. SN #5 acknowledged she failed to document the reason for the missed visit in Patient #5's clinical record; a missed visit notification in Patient #5's clinical record, or to inform Patient #5's doctor of the missed visit. 3. The clinical record for Patient #6 was reviewed on 7/27/23. The POC for the certification periods dated 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23 revealed a start of care date of 10/6/21; diagnosis included leukemia, HTN and drug-induced polyneuropathy. The POC orders included SN one to six times per week every two weeks depending on the patient status/chemotherapy rounds (no duration was provided - Cross Reference G574) for assessment, patient education, lab collection PRN/ordered, foot and nail care, compliance with medication, administration of subcutaneous injection of Cytarabine 30 mg (chemotherapy medication) under skin daily on days one through seven of each 28 day cycle, daughter to administer medication on the weekends. a) The agency failed to ensure SN visits were provided as ordered. Review of SN notes from 3/27/23 to 7/26/23 failed to show a SN visit was completed every two weeks as ordered. Documentation of SN visits for Patient #6 completed by SNs #5 and #8 showed five SN visits were completed the week of 4/23/23 to 4/29/23 and the next SN visit was completed three weeks later on 5/15/23 by SN #5. Patient #6's record failed to show documentation of a SN visit for the week of 5/7/23 to 5/13/23. Review of SN visits for Patient #6 showed SN #5 completed a visit on 6/27/23 and the next SN visit for Patient #6 was completed three weeks later on 7/20/23 by SN #8. Patient #6's record failed to show documentation of a SN visit for the week of 7/9/23 to 7/15/23. The agency failed to show documentation Patient #6 was provided with two SN visits as ordered. During an interview on 8/1/23 at 1:45 p.m., SN #5 acknowledged she was the SN in charge of Patient #6's SN needs. SN #5 stated the primary reason for SN visits for Patient #6, was Patient #6 was unable to inject his chemotherapy medication, Cytarabine, due to his neuropathy. SN #5 stated Patient #6 received his Cytarabine injections for seven days in a row every four to six weeks as ordered by his oncologist. Patient #6's daughter could assist Patient #6 with these injections on Saturday and Sunday, but not during the week due to the daughter's job. SN #5 provided visits to Patient #6 Mondays through Wednesdays and SN #8 provided visits Thursdays and Fridays. SN #5 stated she completed SN visits in between chemotherapy rounds to assess how Patient #6 was tolerating his medications including his chemotherapy and to allow the SN to assess Patient #6's lungs every two to three weeks, but acknowledged the SN order was for visits every two weeks. SN #5 stated she tracked Patient #6's visits on her phone and acknowledged she missed two weeks of visits for Patient #6. SN #5 acknowledged she failed to write a missed visit or to inform Patient #6's doctor of these two missed visits. 4. The clinical record for Patient #10 was reviewed on 8/1/23. The POC for the certification period dated 3/3/23 to 5/1/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders included SN one time a week for one week and three PRN visits based on the condition of the patient for assessment, patient education, pain management, obtain lab specimens PRN as ordered, compliance with medications, and anticoagulation monitoring; PT evaluation and treatment for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment for assessment and education regarding activities of daily living (ADL) and safety. Review of the POC for the certification period dated 5/2/23 to 6/30/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders included PT one to two times a week for eight weeks for assessment and education to improve safety and functional mobility independence. a) The agency failed to ensure PT visits were provided as ordered. Review of referral orders from Patient #10's primary care physician (PCP) showed PT evaluation and treatment was ordered on 2/27/23. Review of Patient #10's clinical record revealed PT #9 conducted a PT evaluation on 3/13/23, 15 days after PT was ordered and 11 days after SN #8 completed a start of care assessment for Patient #10. Review of a PT POC dated 3/13/23 completed by PT #9 showed PT #9 had a verbal order from Patient #10's PCP to start PT on 3/15/23 per patient request. Review of PT notes from 3/13/23 to Patient #10's discharge from PT and the agency on 6/2/23 failed to show a PT visit was completed the weeks of 4/16/23 to 4/22/23 and 5/21/23 to 5/27/23, a total of two missed PT visits for Patient #10. During an interview on 8/1/23 at 12:44 p.m., PT #9 stated he did not recall what date the administrator or alternate administrator informed him he had PT evaluation and treatment orders for Patient #10. PT #9 stated he remembered Patient #10 had many appointments and canceled scheduled visits for the evaluation multiple times. PT #9 acknowledged he failed to document his attempts to evaluate Patient #10 in a timely manner and Patient #10's cancellation of appointments. PT #9 stated during his evaluation on 3/13/23, he informed Patient #10's PCP of the delayed timing of the PT evaluation and received a verbal order for the delayed PT start of care for 3/15/23, which PT #9 stated, was a typo and should have been documented for 3/13/23. PT #9 stated he should have contacted Patient #10's PCP when PT #9 experienced difficulty scheduling the PT evaluation and not after the fact as PT #9 stated it occurred. During continued interview, PT #9 acknowledged he missed two visits for Patient #10 the week of 4/16/23 to 4/22/23 and 5/21/23 to 5/27/23 and failed to document the reason for the missed visits, failed to document a missed visit order for either missed visit and failed to notify Patient #10's PCP of the missed visits. PT #9 stated he could not recall why Patient #10 did not receive therapy those two weeks, but he thought it was because Patient #10 had doctor appointments. PT #9 stated he failed to inform Patient #10's PCP of the missed PT visits for those two weeks as Patient #10 was at the PCP's office during those missed visits. 5. The clinical record for Patient #7 was reviewed on 7/26/23. The POC for the certification period dated 6/25/23 to 8/23/23 revealed a start of care date of 12/27/22; diagnosis included acute embolism and thrombosis of right femoral vein, acute combined systolic and diastolic heart failure, rheumatoid arthritis, chronic respiratory failure with hypoxia, chronic kidney disease, rheumatic mitral stenosis and legal blindness. The POC orders included SN one to three times per two weeks for nine weeks for ongoing assessment, disease process education and symptom management; and HHA four times a week for nine weeks for assistance with personal care and ADL. a) The agency failed to ensure HHA services were provided as ordered. Review of HHA notes for Patient #7 showed Patient #7 received four HHA visits the week of 6/25/23 to 7/1/23 (6/25/23, 6/27/23, 6/30/23, and 7/1/23). There was no evidence of any further HHA visits after 7/1/23.From 7/2/23 until 7/26/23 the agency failed to show documentation Patient #7 was provided with 14 HHA visits as ordered. Review of a verbal order dated 7/1/23 but signed by SN #5 and entered into Patient #7's clinical record on 7/30/23 showed HHA services were discharged on 7/1/23 due to Patient #7 moving into an assisted living facility (ALF). During an interview on 8/2/23 at 2:47 p.m., the administrator stated the agency expected clinicians to document verbal orders they received from physicians within three to five days of receipt of the order. The administrator acknowledged the discharge HHA verbal order written by SN #5 29 days after receipt of the order was not timely. The administrator stated she would re-educate all SNs and therapists on the agency's expectation to write timely verbal orders and to communicate with physicians in a timely manner. 6. During an interview on 8/2/23 at 1:34 p.m. the administrator stated she and/or the alternate administrator informed therapists of therapy orders received for a patient. The administrator stated the agency tracked these referral therapy orders and which therapist the agency assigned, to ensure therapy evaluations were completed as ordered. The administrator stated if a therapy order was received by a SN, typically the SN would communicate these orders to the therapist. The administrator stated SN #5 struggled with remembering to inform therapists of evaluation orders she received more than the other two SNs at the agency (SNs #8 and #13) as SN #5 had another job. The administrator acknowledged the agency's system of tracking referral orders and who the agency assigned to complete the order was not working or documented in the patient's clinical record. During an interview on 8/2/23 at 2:42 p.m., the administrator stated each clinician was responsible for tracking visit frequency and the agency expected all disciplines providing care to a patient to document a missed visit with the reason the visit was missed if they are unable to complete a visit as scheduled. The agency's electronic medical record (EMR) tracked all documented missed visits; the agency administrator ran a missed visit report each week; and the administrator faxed the missed visits to each patient's PCP respectively. If a clinician failed to document a missed visit, the administrator would not be alerted if a missed visit occurred as the agency's EMR did not track undocumented missed visits.

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 interview and record review, the agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 7 active patients reviewed (Patient #5). Findings include: AGENCY POLICY According to an undated agency policy titled, Comprehensive Assessment Policy & Procedure/Care Plan Development & Review Process Policy & Procedure, (read in pertinent parts): "The physician orders are obtained at the Start of Care of patient services. There are periodic interim orders obtained from the physician between certifications which are sent for signature with any changes in Plan of Care. During the course of care, contact is made with the physician regarding changes in treatment and/or medications and there is follow up with appropriate interim orders." 1. The clinical record for Patient #5 was reviewed on 7/26/23. The plan of care for the certification period dated 6/5/23 to 8/3/23 revealed a start of care date of 6/5/23; diagnosis included unspecified open wounds on the right and left leg, repeated falls, degenerative disease of the nervous system, osteoarthritis, hypertension, major depressive disorder, osteoporosis, immunodeficiency, cachexia, and other abnormalities of gait and mobility. The plan of care orders included skilled nursing (SN) one to two times per week for nine weeks depending upon patient condition for assessment, patient education, lab collection as needed (PRN)/ordered, compliance with medication, and wound care; physical therapy (PT) evaluation and treat one time a week for nine weeks for assessment, gait training, education on safety precautions, pain management, strengthening/conditioning exercises, balance/coordination training, and transfer training; occupational therapy (OT) evaluation and treat one time a week for nine weeks for assessment, activities of daily living (ADL) training, safety precautions, pain management, and strengthening/conditioning exercises; and home health aide (HHA) two times a week for nine weeks for assistance with personal care and ADLs. a) The agency failed to ensure orders were obtained to start care with the patient. Review of Patient #5's clinical record revealed SN #5 completed a comprehensive assessment for Patient #5 on 6/5/23. Additionally, record review revealed on 6/5/23 SN #5 completed the following wound care to Patient #5's left leg, left arm and right hand: "cleansed with saline, patted dry, applied silvasorb ointment, covered with bordered gauze. SN #5 failed to have orders to for the assessment and wound care she completed with Patient #5 on 6/5/23. Further review of Patient #5's clinical record showed a referral order was faxed to agency on 6/9/23 at 11:08 a.m. from Patient #5's primary care physician (PCP) ordering the SN to assess Patient #5's surgical site, debridement site and pain level; OT and PT to evaluate and treat; and HHA for personal care effective 6/9/23, four days after SN #5 completed a comprehensive assessment evaluation of Patient #5. Patient #5's clinical record failed to show evidence of an order to begin skilled care effective 6/5/23. During an interview on 8/1/23 at 1:45 p.m., SN #5 stated she was informed to begin care for Patient #5 by agency office personnel although she could not recall who specifically contacted her to inform her to complete the comprehensive assessment with Patient #5 on 6/5/23. SN #5 stated typically she found referral orders for a patient in the patient's clinical record in the agency's electronic medical record (EMR), but occasionally the office staff did not always have time to upload the referral documents prior to SN #5 completing her comprehensive assessment with a patient. During an interview on 8/2/23 at 2:05 p.m., the administrator stated the agency received a phone call from Patient #5's PCP ordering the agency to start skilled services including SN, PT, OT, and HHA for Patient #5 prior to the agency receiving the order on 6/9/23. The administrator acknowledged the agency failed to document this conversation with Patient #5's PCP and a verbal order was not documented for start of care orders for Patient #5 on 6/5/23. b) The agency failed to ensure SN and HHA services were provided only as ordered by the physician. Review of Patient #5's plan of care for certification period dated 6/5/23 to 8/3/23 failed to reveal verbal orders for the plan of care had been received from Patient #5's PCP. Review of this plan of care showed it was signed by Patient #5's PCP on 7/5/23. Review of Patient #5's clinical record showed Patient #5 received SN visits on 6/13/23, 6/19/23, 7/3/23, 7/10/23, and 7/17/23 and a HHA visit on 6/17/23. Further review of Patient #5's clinical record failed to show a verbal order was received for care provided to Patient #5 at her three SN visits (6/13/23, 6/19/23, and 7/3/23) and her HHA visit completed prior to Patient #5's PCP signing Patient #5's plan of care on 7/5/23. During an interview on 8/1/23 at 2:13 p.m., SN #5 stated after she completed a comprehensive assessment with a patient, she would call the patient's PCP to inform him/her of her assessment and plan of care to receive a verbal order for care provided prior to the PCP reviewing and signing the patient's plan of care. SN #5 believed she made this phone call to Patient #5's PCP on 6/5/23 after completing Patient #5's comprehensive assessment, but acknowledged she failed to document this conversation or to document she received a verbal order. During an interview on 8/2/23 at 2:15 p.m., the administrator acknowledged the agency failed to obtain a verbal order for SN and HHA visits provided to Patient #5 from her start of care on 6/5/23 until Patient #5's PCP signed Patient #5's plan of care on 7/5/23. The administrator stated she would re-educate SN #5 on the regulation which required all services and treatment be provided only as ordered by a physician and the need to obtain a verbal order for services and treatment provided prior to a patient's PCP signing a patient's plan of care. c) The agency failed to ensure wound care was provided only as ordered by the physician. Further review of Patient #5's plan of care for the certification 6/5/23 to 8/3/23 signed by Patient #5's PCP on 7/5/23 showed the following wound care orders: -"SN to perform wound care to skin tears to left leg, left arm and hand. Cleanse wound with saline or wound cleanser, apply silvasorb (protects and hydrates dry wounds utilizing microscopic particles of controlled-release ionic silver), cover and secure with bordered gauze or mepilex border (a self-adherent, multifoam wound dressing), change every seven days and as needed." Review of Patient #5's clinical record failed to show any other orders for wound care for Patient #5. Review of a SN note for Patient #5 on 6/19/23 showed SN #5 documented she was able to view Patient #5's right leg which had two wounds. SN #5 documented she provided Patient #5 with wound care as ordered on the plan of care of cleanse with sterile water, applied silvasorb, and covered with bordered gauze for the following five wounds: left lower leg, left arm, right hand, and two on Patient #5's right leg, however the plan of care orders did not include orders for wound care to Patient #5's two right lower extremity wounds and SN #5 failed to obtain verbal orders for wound care for Patient #5's two right lower extremity wounds. Review of a SN visit for Patient #5 on 7/3/23 showed SN #5 documented Patient #5 had two wounds on her left leg, a skin tear and a hematoma. SN #5 documented on Patient #5's left leg hematoma she applied gauze and a bordered foam dressing to protect the area, and Patient #5's PCP stated to not open "left leg dressing" and SN #5 would follow up with the Patient #5's PCP on 7/5/23. SN #5 documented she cleansed Patient #5's left lower extremity skin tear with sterile water, applied silvasorb ointment and covered with bordered gauze and provided wound care for Patient #5's left arm, and two right leg wounds (Wounds #4 and #5) as ordered in interventions on the plan of care for the certification 6/5/23 to 8/3/23. However, the plan of care orders did not include orders for wound care to Patient #5's two right lower extremity wounds and SN #5 failed to document the verbal order for the wound care she provided to Patient #5's new left lower extremity hematoma. Review of a SN visit for Patient #5 on 7/10/23 showed SN #5 documented she cleansed Patient #5's "hematoma area, left lower leg, with sterile water, applied silvasorb ointment and covered with bordered foam." SN #5 failed to have an order for the wound care provided to Patient #5's left leg hematoma. Review of a SN visit for Patient #5 on 7/17/23 showed SN #5 documented she cleansed Patient #5's left lower front leg hematoma and right leg two wounds (Wounds #4 and #5) with sterile water, applied silvasorb ointment and covered with a bordered foam bandage. SN #5 failed to have orders for the wound care she provided to Patient #5's left lower front leg hematoma and to her two right lower extremity wounds. During an interview on 8/1/23 at 1:55 p.m., SN #5 stated she failed to obtain orders for the wound care she provided to Patient #5's right leg. SN #5 stated Patient #5 was being treated for her wounds by several different doctors including at a wound care clinic and by a podiatrist. SN #5 stated she had previously provided SN care to Patient #5 for wound care and Patient #5's podiatrist would not return phone calls or sign orders for wound care. SN #5 stated due to the difficulties she experienced obtaining orders from Patient #5's podiatrist during previous treatment episodes, SN #5 sought initial wound care orders for Patient #5's three wounds (her left leg, left arm and right hand skin tear wounds) she assessed on Patient #5 during her comprehensive assessment on 6/5/23. SN #5 stated she did not call Patient #5's PCP or podiatrist for wound care orders for the wound care she provided to Patient #5's two right lower extremity wounds. SN #5 stated one of the wounds on Patient #5's right lower extremity was a surgical wound that SN #5 was unable to assess during her 6/5/23 comprehensive assessment due to the wound being covered by a surgical dressing. On 6/19/23, SN #5 was able to assess Patient #5's right surgical wound and second wound on Patient #5's right leg. Patient #5's son was present for the 6/19/23 SN visit and SN #5 stated Patient #5's son instructed SN #5 on what wound care to provide to Patient #5 right lower extremity wounds based on the wound care he observed at Patient #5's podiatry appointment, but she instructed Patient #5's son she would need written orders to provide the wound care he suggested from the podiatrist. Instead, SN #5 stated she provided the same wound care ordered for Patient #5's three other wounds which she received from Patient #5's PCP and acknowledged she failed to call Patient #5's PCP to ensure he wanted SN #5 to follow the wound care orders provided for Patient #5's left leg, left arm and right arm skin tears to her right lower extremity surgical wound and the new right lower extremity hematoma. During an interview on 8/2/23 at 2:10 p.m., the administrator reviewed Patient #5's clinical record including her orders and acknowledged SN #5 failed to obtain orders for all of the wound care she provided. The administrator stated SN #5 should not have assumed orders she obtained for her left leg, left arm and right hand skin tears applied to the two wounds SN #5 treated on Patient #5's right leg. The administrator stated the agency expectation was any time there was a change in a patient's need from their plan of care orders, the SN or therapist was expected to call the patient's physician to obtain an interim order to provide the care the patient required and to document this order as a verbal order in the patient's clinical record.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient's plan of care (POC) was reviewed by the physician at least every 60 days for 2 of 6 patients reviewed who were on services longer than 60 days (Patients #6 and #9). Findings include: AGENCY POLICY According to an undated agency policy titled, Comprehensive Assessment Policy & Procedure/Care Plan Development & Review Process Policy and Procedure, (read in pertinent parts): "The physician orders are obtained at the Start of Care of patient services. There are periodic interim orders obtained from the physician between certifications which are sent for signature with any changes in Plan of Care. During the course of care, contact is made with the physician regarding changes in treatment and/or medications and there is follow up with appropriate interim orders. Every sixty days a complete review is performed for recertification and sent to the M.D." 1. The clinical record for Patient #9 was reviewed on 7/27/23. The POC for the certification periods dated 3/3/23 to 5/1/23 and 5/2/23 to 6/30/23 revealed a start of care date of 7/29/23 (inaccurate start date - Cross reference G574); diagnosis included neuromuscular dysfunction of bladder, cerebral infarction, peripheral vascular diseases, polyneuropathy, mild cognitive impairment and heart disease. The POC orders included SN one to two times per two weeks for nine weeks for catheter changes, symptom management and ongoing assessment. a) Clinical record review showed the POC was not reviewed and approved by the physician at least every 60 days. Review of Patient #9's POC for the certification period dated 3/3/23 to 5/1/23, revealed the physician had not reviewed and signed the POC for the entire 60 day service period. Additional review showed the physician reviewed and signed the POC on 7/21/23, 81 days after the certification period ended. Review of Patient #9's POC for the certification period dated 5/2/23 to 6/30/23, revealed the physician had not reviewed and signed the POC for the entire 60 day service period. Additional review showed the physician reviewed and signed the POC on 7/21/23, 21 days after the certification period ended. During an interview on 8/2/23 at 3:30 p.m., the administrator stated the POCs for Patient #9 were faxed to her physician multiple times for review and signature. Specifically, the administrator stated for the certification period 3/3/23 to 5/1/23 was faxed to Patient #9's physician for signature on 3/10/23 and 5/12/23 and the POC for the certification period 5/2/23 to 6/30/23 was faxed to Patient #9's physician for signature on 5/10/23. The administrator stated Office Assistant #12 probably faxed both POCs more often, but failed to document those attempts in the electronic medical record. 2. The clinical record for Patient #6 was reviewed on 7/27/23. The POC for the certification periods dated 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23 revealed a start of care date of 10/6/21; diagnosis included leukemia, HTN and drug-induced polyneuropathy. The POC orders included SN one to six times per week every two weeks depending on the patient status/chemotherapy rounds (no duration was provided - Cross reference G574) for assessment, patient education, lab collection as as needed (PRN)/ordered, foot and nail care, compliance with medication, administration of subcutaneous injection of Cytarabine 30 mg (chemotherapy medication) under skin daily on days one through seven of each 28 day cycle, daughter to administer medication on the weekends. a) Clinical record review showed the POC was not reviewed and approved by the physician at least every 60 days. Review of Patient #6's POC for the certification period dated 3/30/23 to 5/28/23, revealed the physician had not reviewed and signed the POC for the entire 60 day service period. Additional review showed the physician reviewed and signed the POC on 6/9/23, 12 days after the certification period ended. During an interview on 8/2/23 at 3:30 p.m., the administrator stated she had no documentation to show when Patient #6's POC for the certification period dated 3/30/23 to 5/28/23 was faxed to Patient #6's physician for review and signature. 3. During an interview on 8/2/23 at 3:30 p.m., the administrator stated the agency process for sending POCs to physicians for review was once a clinician completed and signed a POC, the POC would be added to the quality assurance (QA) list to be reviewed. The administrator stated since the agency's QA nurse retired in February of 2023, either the administrator or alternate administrator would review the POC for accuracy and completeness. Once the QA process was completed, Office Assistant #12 would fax the POC to the physician for signature. The administrator stated Office Assistant #12 would go through the agency's patient list regularly to see what items had been faxed but not returned and would resend those items for signature. The administrator stated she expected Office Assistant #12 to document in each patient's clinical record all attempts made by the agency to send POCs and orders to physicians for signature. The administrator stated after reviewing Patient #6's and Patient #9's clinical records the agency's tracking system for ensuring POCs were reviewed and signed every 60 days was not sufficient.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure communication with all physicians involved in the plan of care; failed to integrate orders to ensure the coordination of all services and interventions provided to the patient; and failed to coordinate care delivery to meet patient's needs for 6 of 10 patients reviewed (Patients #1, #2, #5, #6, #8, and #10). Findings include: AGENCY POLICY According to an undated agency policy titled, Case Conferences, (read in pertinent parts): "Case conferences will be conducted to assure communication among staff members to address changes in the patient's needs, goals, care or service to be provided and/or physician's orders. The Director of Home Care will be responsible for assuring case conferences are conducted and documented by the appropriate staff members at the following intervals: -Within one week of admission; -Every sixty-two (62) days; -When there are significant changes in the patient's condition; and if possible -Prior to discharge." According to an undated agency policy titled, Policy & Procedure for Significant Change in Patient Status Requiring New Plan of Care, (read in pertinent parts): "Patient's Plan of Care, ordered and signed by physician, is normally for 60 days. -Changes such as Wound Care or Nutrition have a signed M.D. order and the new procedures are documented in Progress Notes, then reflected in the next Plan of Care. -If there is a significant change in a patient's condition, there needs to be a new Plan of Care." "With a significant change in a patient's condition, the physician must be aware first." 1. The clinical record for Patient #1 was reviewed on 7/26/23. The plan of care (POC) for the certification period 4/21/23 to 6/19/23 revealed a start of care date of 3/13/19; diagnosis included paraplegia, type two diabetes, neuromuscular dysfunction of bladder, fitting and adjustment of urinary device, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, hereditary factor VIII deficiency, hypothyroidism, fracture of right and left femurs. Plan of care orders included skilled nursing (SN) one to two times every two weeks for nine weeks depending upon the patient status for assessment, education, obtain lab specimens as ordered, change suprapubic catheter every two to three weeks as needed for occlusion, dislodgement, or malfunction of catheter; physical therapy (PT) evaluation and treatment one time a week for nine weeks for assessment and education to improve safety and functional mobility independence; occupational therapy (OT) evaluation and treatment one to two times per week for nine weeks for assessment and education regarding activities of daily living (ADLs) and safety; speech therapy (ST) evaluation and treatment (no further information provided on the POC for ST interventions); and home health aide (HHA) two times a week for nine weeks to provide assistance with personal care and ADLs. a) Clinical record review revealed the agency failed to ensure SN #5 and PT #9 coordinated with Patient #1's physician to obtain precautions following a fall Patient #1 sustained resulting in bilateral femur fractures. Review of Patient #1's record revealed a HHA missed visit note on 6/1/23 completed by HHA #3 which stated the visit was missed due to Patient #1 being hospitalized. Review of Patient #1's record revealed a communication note written on 6/5/23 by SN #5 which stated Patient #1 fell out of bed, went to the hospital, was in the hospital for two days, and per family was then back home. Further review of Patient #1's record failed to show documentation of any communication notes from 6/6/23 until 7/26/23. Review of the clinical record failed to show Patient #1 was assessed by a SN when she returned home from the hospital on 6/3/23 until she was readmitted to the hospital on 6/6/23. Review of a resumption of care assessment completed on 6/13/23 showed SN #5 documented Patient #1 recently discharged from the hospital due to falling out of bed and fracturing her bilateral femurs, as well as being treated for a urinary tract infection (UTI) and anemia. SN #5 documented she discussed Patient #1's POC with Patient #1's primary care physician (PCP), but failed to document what she specifically spoke to the PCP about. Review of the POC for the certification period 4/21/23 to 6/19/23 completed by SN #5 showed SN was to teach on fracture precautions, but failed to specify what the fracture precautions were or who the SN was to teach these precautions too. (Cross reference G574). The POC for the certification period 4/21/23 to 6/19/23 was reviewed and signed by a nurse practitioner (NP) on 4/26/23 and again on 6/26/23. The agency failed to communicate with Patient #1's NP regarding her new bilateral femur fractures sustained on 6/1/23, until 6/26/23, 25 days later. Review of a PT evaluation completed on 6/21/23 showed PT #9 documented he did not perform passive range of motion assessment with Patient #1 due to her bilateral femur fractures and Patient #1 was not a PT candidate at the time of the PT evaluation due to bilateral ankle fractures and bilateral femoral fractures with long term paraplegia. PT #9 failed to document he completed care coordination with Patient #9's SN or the physician regarding Patient #9's bilateral femur fracture precautions. During a home visit on 7/27/23 at 9:02 a.m., Patient #1's son confirmed Patient #1 fell out of bed on 6/1/23 when she tried to get up on her own and sustained fractures to both of her femurs. Patient #1's son stated Patient #1 was suffering from a UTI at the time which made her confused and she forgot she needed help to get out of bed. Patient #1's son stated the fractures were inoperable and the hospital discharged Patient #1 home on 6/3/23. Patient #1's son could not recall any specific precautions Patient #1 had to follow as Patient #1 was non-weight bearing due to her paralysis. During an interview on 7/27/23 at approximately 10:45 a.m., PT #9 confirmed he failed to call Patient #1's physician to clarify what her bilateral femur fracture precautions were. PT #9 stated Patient #1's son informed him during the 6/21/23 PT evaluation, Patient #1 was to be non-weight bearing and no further precautions were stated to Patient #1 or her son upon her discharge from the hospital on 6/3/23. PT #9 stated he did not feel comfortable working with Patient #1 until her fractures healed which he felt would be in six to eight weeks from 6/1/23, but PT #9 acknowledged he failed to care coordinate with Patient #1's primary care physician (PCP) or the orthopedist who evaluated Patient #1 during her hospital stay 6/1/23 to 6/3/23 for her new bilateral femur fractures. During an interview on 8/1/23 at 2:45 p.m., SN #5 stated she added SN to teach fracture precautions to Patient #1's POCs to indicate being careful as Patient #1 had two new fractured femurs from her fall on 6/1/23. SN #5 stated she failed to care coordinate with Patient #1's PCP or the orthopedist, who cared for Patient #1 in the hospital from 6/1/23 to 6/3/23, to receive specific instructions on what precautions the agency clinicians and her family should follow to assist her bilateral femur fractures to heal. SN #5 could not recall why she did not care coordinate with Patient #1's physician regarding precautions for Patient #1's bilateral femur fractures. 2. The clinical record for Patient #10 was reviewed on 8/1/23. The POC for the certification period dated 3/3/23 to 5/1/23 revealed a start of care date of 3/3/23; diagnosis included lumbosacral radiculopathy, polyarthritis, osteoarthritis of both knees, hypertension, atrial fibrillation and disorder of lipoprotein metabolism. The POC orders, signed by Patient #10's PCP on 3/28/23, included SN one time a week for one week and three PRN visits based on the condition of the patient for assessment, patient education, pain management, obtain lab specimens PRN as ordered, compliance with medications, and anticoagulation monitoring; PT evaluation and treatment for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment for assessment and education regarding ADL and safety. a) Clinical record review revealed the agency failed to ensure care coordination regarding the initiation of ordered OT services. Review of the clinical record revealed referral documentation sent to the agency on 2/27/23 from Patient #10's PCP ordering PT evaluation and treatment. On the top of this referral document was a handwritten note which stated disciplines RN, OT and PT. Further review of the POC for the certification period dated 3/3/23 to 5/1/23 revealed SN #8 had obtained a verbal order effective 3/3/23 for all POC orders including OT evaluation and treatment for Patient #10. Review of the clinical record failed to show an OT therapy evaluation had been completed during Patient #10's home health care episode from 3/3/23 to her discharge on 6/2/23. Record review showed no evidence the agency coordinate with the physician regarding their inability or initiate OT services for Patient #10. During an interview on 8/1/23 at 1:20 p.m., OT #4 stated she was familiar with Patient #10's name. OT #4 did not recall ever receiving information from SN #8 or the agency management team to complete an OT evaluation with Patient #10 and confirmed she had not completed an evaluation with Patient #10. During an interview on 8/2/23 at 9:09 a.m., SN #8 could not recall if she informed OT #4 or not regarding the evaluation and treatment orders for Patient #10 effective 3/3/23. SN #8 stated she put OT evaluation and treat on the POC orders based on the information she found on the referral order in the clinical record for Patient #10. SN #8 stated typically she would inform the administrator and/or the alternate administrator when she completed a start of care assessment with a patient and then the administrator/alternate administrator were responsible for coordinating with other ordered disciplines to schedule visits with the patient. During an interview on 8/2/23 at 2:34 p.m., the administrator stated the handwritten note on Patient #10's 2/27/23 referral document which stated SN, PT and OT as disciplines to assess Patient #10 was the administrator's handwriting. The administrator confirmed either she or the alternate administrator coordinated with all disciplines when they had evaluation orders for a patient to ensure the discipline was made aware of the order, scheduled the visit and completed the ordered assessment. The administrator stated she could not recall why OT did not complete an evaluation with Patient #10 and acknowledged the clinical record failed to state why Patient #10 did not receive an OT evaluation. 3. The clinical record for Patient #2 was reviewed on 7/26/23. The POC for the certification period dated 6/16/23 to 8/14/23 revealed a start of care date of 6/20/23 (inaccurate certification dates- Cross reference G574); diagnosis included elevated white blood cell count and type two diabetes mellitus. Plan of care orders included PT evaluation and treatment one to two times a week for eight weeks. a) Clinical record review revealed the agency failed to inform Patient #2's physician when OT services were refused. Review of referral documentation sent to the agency on 6/13/23 by Patient #2's PCP showed Patient #2 was referred for PT and OT evaluation and treatment due to gait disturbance and generalized muscle weakness. Review of the clinical record revealed OT #4 completed a start of care assessment and POC documentation on 6/20/23. Record review failed to show any further OT treatment notes for Patient #2 from 6/21/23 to 7/26/23.There was no documented evidence to show OT #4 coordinated with Patient #2's physician regarding the refusal of OT services. Review of communication notes in the clinical record failed to show OT #4 had communicated with Patient #2's PCP why OT services were not provided after 6/20/23. During a home visit on 7/27/23 at 10:30 a.m., Patient #2 confirmed she had an OT evaluation on 6/20/23 and requested OT services discharge as Patient #2 did not feel she required OT services. During an interview on 8/1/23 at 1:19 p.m., OT #4 confirmed she completed the OT evaluation, start of care comprehensive assessment and POC documentation for Patient #2 on 6/20/23. OT #4 confirmed she only provided Patient #2 one day of care on 6/20/23 as Patient #2 declined further OT services. OT #4 stated she thought she called Patient #2's PCP to inform him Patient #2 declined further OT services, but acknowledged she failed to document this conversation or to get an order to discharge OT services. During an interview on 8/2/23 at 1:53 p.m., the administrator stated the agency expected each discipline to call a patient's PCP to inform him/her if the patient declined further care from a discipline and to obtain an order to discharge their service. The administrator acknowledged OT #4 failed to coordinate this care with Patient #2's PCP. The administrator stated she was responsible for monitoring patient charts to ensure all appropriate orders and care coordination occurred and she did not know why this lack of care coordination was missed during the administrator's quality assurance (QA) review process. 4.The clinical record for Patient #5 was reviewed on 7/26/23. The plan of care for the certification period dated 6/5/23 to 8/3/23 revealed a start of care date of 6/5/23; diagnosis included unspecified open wounds on the right and left leg, repeated falls, degenerative disease of the nervous system, osteoarthritis, hypertension, major depressive disorder, osteoporosis, immunodeficiency, cachexia, and other abnormalities of gait and mobility. The plan of care orders included SN one to two times per week for nine weeks depending upon patient condition for assessment, patient education, lab collection as needed (PRN)/ordered, compliance with medication, and wound care; PT evaluation and treat one time a week for nine weeks for assessment, gait training, education on safety precautions, pain management, strengthening/conditioning exercises, balance/coordination training, and transfer training; OT evaluation and treat one time a week for nine weeks for assessment, ADL training, safety precautions, pain management, and strengthening/conditioning exercises; and HHA two times a week for nine weeks for assistance with personal care and ADLs. a) Clinical record review revealed the agency failed to inform Patient #5's physician when HHA services were discharged. Review of HHA notes showed Patient #5 received one HHA visit on 6/17/23 documented by HHA #3. No further HHA visits were documented. Record review revealed no evidence the agency coordinated with Patient #5's physician regarding the discharge HHA services due to Patient #5's refusal. Review of interim orders in the clinical record failed to show a discharge order for HHA services. During an interview on 7/27/23 at approximately 9:30 a.m., HHA #3 stated when she completed her visit with Patient #5 on 6/17/23, Patient #5 informed HHA #3 she did not want HHA services as Patient #5 felt she could independently complete her personal care and ADLs. HHA #3 stated she advised Patient #5 to inform the agency she no longer required HHA services and HHA #3 stated she told either the administrator or the alternate administrator (she could not recall specifically who she told) Patient #5 no longer desired HHA services. During an interview on 8/1/23 at 2:16 p.m., SN #5 stated Patient #5 did not inform her she no longer desired HHA services. Instead, SN #5 stated HHA #3 and the agency management team informed SN #5 of Patient #5's desire to stop HHA services. SN #5 stated she did not write a discharge order for HHA services or inform Patient #5's PCP, Patient #5 no longer desired HHA services. During an interview on 8/2/23 at 1:22 p.m., the administrator stated the agency expected the SN overseeing a patient's care to coordinate a patient's care with the patient's PCP including communicating with the PCP if a patient requested to have an ordered service discharged. The administrator stated SN #5 should have contacted Patient #5's PCP to inform him Patient #5 no longer desired HHA services. The administrator stated she attempted to monitor patients records and catch when a patient had missing orders, but she struggled to keep up with all of her responsibilities. 5. The clinical record for Patient #8 was reviewed on 7/31/23. The POC for the certification period dated 5/27/23 to 7/25/25 revealed a start of care date of 3/28/23; diagnosis included dementia, laceration to lower leg, polyarthritis, joint disorder, hypothyroidism, Vitamin B deficiency, muscle weakness and abnormalities of gait and mobility. The POC orders included SN one to three times a week for four weeks then one to two times a week every two weeks for 60 days based on the condition of the patient for assessment, patient education, obtaining lab specimens PRN as ordered, compliance with medications, and wound care. a) Clinical record review revealed the agency failed to ensure SN #8 documented care coordination she had with Patient #8's physician regarding wound care. Review of the POC for the certification period 5/27/23 to 7/25/23 for Patient #8 showed SN #8 documented a wound care intervention as follows: "SN to perform wound care to bilateral anterior lower tibia dermal tears. Cleanse wounds with normal saline or wound cleanser, pat dry; apply non-stick dressing, cover with ABDs (non-woven thick and absorbent wound care dressing), wrap with conform gauze and secure with tape, using aseptic technique. Apply tubi grip (a elasticated tubular bandage that provides firm support) to bilateral lower extremity toes to knees." The intervention failed to list how often SN was to perform wound care for Patient #8. (Cross Reference G574) Review of SN notes from 5/29/23 to Patient #8's discharge on 7/3/23 showed SN #8 documented she completed wound care to Patient #8's bilateral lower extremities on 5/29/23 and 6/1/23. SN #8 documented on 6/6/23 she completed wound care to Patient #8's right lower extremity as ordered and cleansed Patient #8's left lower tibia wound and left it open to air. In the visit narrative of her note, SN #8 documented she coordinated with Patient #8's healthcare team regarding her POC, but failed to document specifically who she spoke with and what she discussed. In the care coordination section of Patient #8's 6/1/23 SN note, SN #8 documented she care coordinated with a SN (failed to list which nurse), and a primary care physician (failed to provide the name of the physician); documented in the name/title of the care coordination note patient and caregiver (failed to document who the caregiver was); and in the regarding section of the note documented "POC," with no further information documented on what specifically was discussed. Review of Patient #8's 6/13/23 SN visit note showed SN #8 documented in the intervention section of her note both anterior tibial wounds were healed and no longer required wound care and she educated the unskilled caregiver on use of Acetaminophen- uses and side effects. In the visit narrative of the note, SN #8 documented she coordinated with the healthcare team regarding the POC, but failed to document specifically who she spoke with and what she discussed. In the care coordination section of Patient #8's 6/1/23 SN note, SN #8 documented she care coordinated with a SN (failed to list which nurse), and a primary care physician (failed to provide the name of the physician); documented in the name/title of the care coordination note patient and caregiver (failed to document who the caregiver was); and in the regarding section of the note documented "POC," with no further information documented on what specifically was discussed. Review of the interim orders for Patient #8 failed to show documented orders to discharge wound care to Patient #8's right or left lower leg. Review of communication notes for Patient #8 from 5/27/23 to her discharge on 7/3/23 failed to show any communication between SN #8 and Patient #8's PCP to discharge wound care. During an interview on 8/2/23 at 8:34 a.m., SN #8 stated when she completed a care coordination note she attempted to ensure she documented all people involved in the patient's care who she completed care coordination with at each visit. The SN note format in the agency's electronic medical record (EMR) was set up to allow SN #8 to pick the people on the patient's care team from a drop down box to enter in the line titled "Care Coordinated with." If SN #8 provided care coordination with the patient, a family member or a caregiver who did not work for the agency, SN #8 would document an abbreviated name of those people under the section of the note titled "Name/Title," such as "pt" for patient and "cg" for caregiver. Finally, SN #8 acknowledged she often documented in the regarding section: plan of care, to indicate she had discussed some aspect of the patient's POC with the individuals she documented in the other two categories of the care coordination note. During continued interview, SN #8 stated she spoke with Patient #8's PCP weekly when she cared for Patient #8. SN #8 stated she received a verbal order to discontinue wound care to Patient #8's left lower extremity on 6/1/23 and for Patient #8's right lower extremity on 6/13/23, but acknowledged she did not document a verbal order for either time she spoke with Patient #8's PCP as she did not realize she needed to write an interim order when she stopped wound care as directed from the physician. SN #8 acknowledged her care coordination notes failed to provide specific information on who she spoke to and what she discussed at each visit with each person. 6. The clinical record for Patient #6 was reviewed on 7/27/23. The POC for the certification periods dated 3/30/23 to 5/28/23 and 5/29/23 to 7/27/23 revealed a start of care date of 10/6/21; diagnosis included leukemia, HTN and drug-induced polyneuropathy. The POC orders included SN one to six times per week every two weeks depending on the patient status/chemotherapy rounds (no duration was provided - Cross Reference G574) for assessment, patient education, lab collection PRN/ordered, foot and nail care, compliance with medication, administration of subcutaneous injection of Cytarabine 30 mg (chemotherapy medication) under skin daily on days one through seven of each 28 day cycle, daughter to administer medication on the weekends. a) Clinical record review revealed the agency failed to ensure SN #5 and SN #8 documented accurate care coordination notes. Record review showed SN #5 documented on Patient #6's SN notes on 4/17/23, 4/24/23, 4/25/23, 6/6/23, and 6/27/23 she completed care coordination with SN #8, the administrator(documented as the clinical manager in SN #5 visit notes), and Patient #6's PCP regarding Patient #6's POC. SN #5 documented on Patient #6's SN notes on 5/15/23 and 7/24/23 she completed care coordination with the administrator and Patient #6's PCP regarding Patient #6's POC. During an interview on 8/1/23 at 3:08 p.m., SN #5 stated she did not complete care coordination with Patient #6's PCP, SN #8 and the administrator regarding Patient #6's POC on each visit as she documented. SN #5 stated a fellow SN (she could not recall who specifically) told SN #5 each note needed to contain the statement the SN completed care coordination with the patient's PCP and administrator regarding the POC whether SN #5 completed this care coordination or not. SN #5 stated if something significant happened during a patient's SN visit with her and she care coordinated the event with other members of the agency, the patient's family and/or PCP, SN #5 documented the specific care coordination she completed. Record review showed SN #8 documented on 7/20/23 in the care coordination section of the visit note she care coordinated with a SN and Patient #6's PCP. Under the name/title section of the care coordination note, SN #8 documented she care coordinated with Patient #6 and his spouse. Under the regarding section of the care coordination note, SN #8 documented "POC." In the intervention section of her 7/20/23 SN note, SN #8 documented she re-instructed Patient #6 and his spouse on the importance of taking deep breaths and performing daily exercises as tolerated. No further documentation was found regarding what specifically SN #8 discussed with Patient #6's physician or which SN she care coordinated with regarding Patient #6. During an interview on 8/2/23 at 8:34 a.m., SN #8 stated when she completed a care coordination note, she attempted to ensure she documented all people involved in the patient's care who she completed care coordination with at each visit. The SN note format in the agency's electronic medical record (EMR) was set up to allow SN #8 to pick the people on the patient's care team from a drop down box to enter in the line titled "Care Coordinated with." If SN #8 provided care coordination with the patient, a family member or a caregiver who did not work for the agency, SN #8 would document an abbreviated name of those people under the section of the note titled "Name/Title," such as "pt" for patient and "cg" for caregiver. Finally, SN #8 acknowledged she often documented in the regarding section: plan of care, to indicate she had discussed some aspect of the patient's POC with the individuals she documented in the other two categories of the care coordination note. SN #8 acknowledged a more specific note regarding what was discussed would be appropriate. SN #8 stated she could not recall speaking with Patient #6's PCP on 7/20/23 as she documented. 7. During an interview on 8/2/23 at 1:25 p.m., the administrator stated prior to February 2023, the agency had a quality assurance (QA) nurse who assisted the administrator and the alternate administrator with tracking if care coordination occurred appropriately including ensuring physician orders were obtained for all treatments and disciplines, ensuring all orders were completed, and clinicians were writing accurate and complete care coordination notes. The administrator stated, since the QA nurse who performed these tasks retired in February 2023, the responsibility fell to the administrator, and the alternate administrator assisted her when she could. The administrator stated she did not have enough time to keep up with all of her job responsibilities and many tasks were not completed as required by regulation or agency expectation. The administrator stated she planned to assign some of the QA duties to SN #14 to assist the agency to get back in compliance with regulations and agency expectations.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.65, QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT was out of compliance. A total of 10 clinical records were reviewed for compliance with the Condition and Standards of Quality Assessment and Performance Improvement. Record review revealed a pattern of failures in regard to the home health agency ensuring care and services provided met the patient's needs. Record review revealed the agency had failed to implement a program which analyzed the agency's services and operations through collection of data to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement with specific performance improvement projects (PIPs) with documented measurable progress. Additionally, the agency's governing body failed to provide oversight that this program was implemented and maintained in order to identify and correct concerns within the agency's operations that affect patient quality of care and services provided. These failures had the potential to affect all patients served by the home health agency. Findings include: Based on record review and interview, the agency failed to implement a quality assessment and performance improvement (QAPI) which evaluated all agency services and complied with the requirements and standards set forth in Code of Federal Regulations 484.65. 1. On 7/26/23 at 10:35 a.m., 1:25 p.m. and 4:17 p.m., the agency's QAPI was requested for review by the surveyor; which was provided for review by the administrator on 7/27/23 at 11:33 a.m. a. The agency failed to ensure a QAPI program which met quarterly to review collected data, which reviewed the scope of the agency and was utilized to determine agency performance improvement projects (PIPs) to improve quality of care. Review of the QAPI program provided on 7/27/23 at 11:33 a.m. revealed the most recent note which read "first quarter 2023 review January to March 2023- 5 current and 5 discharged charts reviewed; Findings: wound measurements are being documented at least 1x/week and as need (PRN)- much improved; frequency and duration stated and followed; Needs improvement- Face to Face forms are usually timely, needs better follow up with md (physician) to get face to face completed." The note failed to reveal members of the QAPI committee involved or a date when a meeting was held regarding the QAPI. Record review within this folder of charts audited revealed ten charts had been audited; however, the data had not been collected or analyzed in order to identify areas for improvement, or if there had been improvement from the previous QAPI review. Further record review of the QAPI program revealed a note which read "4th quarter 2022- 5 current and 5 discharged charts; current charts show much improvement from past problems; 1 antibiotic are given accurately and timely; doctors orders are being returned in timely manner; all therapies initiated with 5 days of order; needs consistent wound measurements (sic) at least 1x week needs to be more consistent". The note failed to reveal members of the QAPI committee involved or a date when a meeting was held regarding the QAPI. Record review within this folder of charts audited revealed ten charts had been audited; however, the data had not been collected or analyzed in order to identify areas for improvement, or if there had been improvement from the previous QAPI review. Further record review of the QAPI program revealed the Third Quarter July to September 2022 notes included percentages related to data collection from review of ten charts regarding plans of care, interim orders, skilled nursing (SN) services, physical therapy (PT) services, occupational therapy (OT) services, home health aid (HHA); speech language pathologist (ST) therapy, medical social worker (MSW) and administration. This note revealed areas requiring education and improvement which included medication teaching, case conferences, discharge summaries, discharge orders, referrals and start of care orders; however, failed to reveal a specific measurable goal for improvement or timeline for expected improvements. Record review failed to reveal QAPI review, including chart audits, or meetings had been documented between March to July 2023. Record review further failed to reveal documentation of review of adverse patient experiences which included incidents including falls, hospitalizations or complaints within the QAPI review. During an interview on 7/27/23 at 3:30 p.m., the administrator and alternate administrator stated the current QAPI identified PIPs related to face to face documentation by the physician was maintained within the records and this issue had been identified related to billing concerns without this documentation and that this concern has been improving because billing had improved. The administrator and alternate administrator stated the other current PIP at the agency included ensuring patient wounds were measured and documented within the record weekly; however, this had not been determined utilizing data and was something the agency administration thought was important. The administrator and alternate administrator acknowledged this was not clearly documented within the QAPI program. During further interview, the administrator stated that as clinicians complete documentation and add the documentation into the electronic medical record (EMR), the administrator reviewed the clinician's notes as quality assurance daily; however, had not completed review of clinician documentation regarding timeliness or accuracy in review of completion. During further review on 7/27/23 at 3:55 p.m., the administrator stated the agency QAPI program aimed to ensure patient outcomes were improving which was reviewed within clinician notes and the administrator was tracking mentally; however, had not written down improvements or noted concerns during quality assurance review of clinician documentation daily. The administrator stated there had been a QAPI designated personnel who had left in February 2023 and the administrator had overseen QAPI since then. The administrator acknowledged the agency was overdue for a quarterly QAPI meeting regarding services provided between April to June 2023. b. The agency failed to ensure the QAPI data collected included information that had been accurately reviewed. On 8/1/23 at 9:30 a.m., the administrator stated she had additional QAPI information for surveyor review after discussion with surveyors on 7/27/23. The administrator provided the additional QAPI information which included a QAPI meeting that had been completed on 7/30/23 and included review of ten records between April to July 2023. Of the ten records reviewed, one discharged patient record had been reviewed by the surveyors on 7/27/23, Patient #8. Record review of the chart audit completed for Patient #8 on 7/30/23 revealed Patient #8 had 100% compliance with all applicable areas of care which included certification and plan of care, interim orders, recertification, SN services, PT services, OT services, consents and advanced directives and periodic reassessment and alteration in patient care plan. On 8/1/23, review of the record review completed on 7/30/23 revealed the following discrepancies between the agency quality assurance review and surveyor record review: -The agency documented Patient #8 was an active patient though reviewed simultaneously discharge paperwork and orders indicating Patient #8 had discharged on 7/3/23; -The agency documented Patient #8 had a complete and accurate plan of care, however, Patient #8's plan of care failed to reveal wound care orders contained a frequency; and -The agency documented Patient #8's record maintained all necessary interim orders; however, SN #8 had failed to obtain an order to stop wound care for Patient #8 from a physician prior to no longer providing that care. Further review of the completed QAPI meeting documentation from 7/30/23 failed to reveal documentation of review of adverse patient experiences which included incidents including falls, hospitalizations or complaints within the QAPI review. Record review of the incident log provided for review to surveyors on 7/26/23 failed to reveal falls or hospitalizations for any patients after 6/1/23. Review of patient records revealed falls and/or hospitalizations which were not included within the incident log in order to be utilized within the QAPI review. Specifically: -Patient #1 had a fall on 6/1/23 and hospitalizations 6/1 – 6/3/23, 6/6 – 6/11/23 and 6/22/23; -Patient #4 had a fall on 7/24/23; and -Patient #7 had a fall on 5/22/23 and on 7/24/23. Further review of the QAPI meeting documentation completed on 7/30/23 revealed the agency had not been 100% compliant within the areas of orders and goals which included SN education to patients regarding medication administration (noted 70% compliant) and medications listed on the plan of care (80% compliant). The QAPI meeting documentation revealed these two areas for improvement; however, failed to reveal corrective measures, how the improvements would be monitored and an expected completion date for improvements. During further interview regarding QAPI on 8/2/23 at 2:50 p.m., the administrator stated the incident log is created manually following documentation in a specific incident template by clinicians which is reviewed by the administrator and added to the incident log. The administrator reviewed the clinicians had not completed an incident template for review and she had overseen the documentation of falls or hospitalizations in daily quality assurance reviews of individual clinician notes. The administrator acknowledged the importance of tracking incidents such as falls and hospitalizations within the QAPI program and stated she would re-educate personnel on completing the incident template. The administrator acknowledged the QAPI program and current quality assurance reviews had not been effectively capturing the areas for improvement within the agency and policies, procedures and forms would need to be recreated in order to implement an effective program.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that home health aids (HHA) provided services in accordance with the patient plan of care in 3 of 3 patients reviewed who received HHA services (Patients #1, #5 and #7). Findings include: 1. The clinical record for Patient #5 was reviewed on 7/26/23. The plan of care (POC) for the certification period dated 6/5/23 to 8/3/23 revealed a start of care date of 6/5/23; diagnosis included unspecified open wounds on the right and left leg, repeated falls, degenerative disease of the nervous system, osteoarthritis, hypertension, major depressive disorder, osteoporosis, immunodeficiency, cachexia, and other abnormalities of gait and mobility. The plan of care orders included skilled nursing (SN) one to two times per week for nine weeks depending upon patient condition for assessment, patient education, lab collection as needed (PRN)/ordered, compliance with medication, and wound care; physical therapy (PT) evaluation and treat one time a week for nine weeks for assessment, gait training, education on safety precautions, pain management, strengthening/conditioning exercises, balance/coordination training, and transfer training; occupational therapy (OT) evaluation and treat one time a week for nine weeks for assessment, activities of daily living (ADL) training, safety precautions, pain management, and strengthening/conditioning exercises; and HHA two times a week for nine weeks for assistance with personal care and ADLs. a. The HHA failed to provide services in accordance with the plan of care for Patient #5. Review of the HHA plan of care, dated 6/5/23, revealed the HHA was to provide personal care services of shower with chair, hair care, skin care, dressing and assistance with transfers and mobility every visit. Review of service documentation between 6/5/23 and 7/25/23 revealed HHA #3 had not provided services between 6/9/23 and 6/16/23 as the first visit with Patient #5 was on 6/17/23; therefore, HHA #3 failed to provide services in accordance with the plan of care frequency of HHA services two days per week. Review of service documentation between 6/5/23 and 7/25/23 revealed HHA #3 provided services to Patient #5 on 6/17/23 only; which was not in accordance with the frequency of two days per week for nine weeks. Record review failed to reveal notification by HHA #5 to registered nurse (RN) #5 regarding the change in plan of care or needs of Patient #5. Additionally, the documentation note on 6/17/23 only stated there were no skin issues to report and failed to reveal any documentation of services having been provided to Patient #5. During an interview on 7/27/23 at approximately 9:30 a.m., HHA #3 stated she arrived to Patient #5's home on 6/17/23 and was told HHA services were not needed as Patient #5 was able to complete services independently and declined further HHA services. HHA #3 further stated she had notified RN #5 of the change in the plan of care. During an interview on 8/1/23 at 2:15 p.m., RN #5 stated she had been aware that HHA #3 had went to Patient #5's home to provide services on 6/17/23 and Patient #5 had declined cares that day and ongoing. RN #5 stated she had not documented this conversation with HHA #3 and failed to obtain an order to discharge HHA services. During continued interview, RN #5 stated she could not remember why HHA #3 had not gone to provide HHA services to Patient #5 until 6/17/23. 2. The clinical record for Patient #1 was reviewed on 7/26/23. The POC for the certification period 4/21/23 to 6/19/23 revealed a start of care date of 3/13/19; diagnosis included paraplegia, type two diabetes, neuromuscular dysfunction of bladder, fitting and adjustment of urinary device, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, hereditary factor VIII deficiency, hypothyroidism, fracture of right and left femurs. Plan of care orders included SN one to two times every two weeks for nine weeks depending upon the patient status for assessment, education, obtain lab specimens as ordered, change suprapubic catheter every two to three weeks as needed for occlusion, dislodgement, or malfunction of catheter; PT evaluation and treatment one time a week for nine weeks for assessment and education to improve safety and functional mobility independence; OT evaluation and treatment one to two times per week for nine weeks for assessment and education regarding ADLs and safety; speech therapy (ST) evaluation and treatment (no further information provided on the POC for ST interventions); and HHA two times a week for nine weeks to provide assistance with personal care and ADLs. a. The HHA failed to provide services in accordance with the plan of care for Patient #1. Review of the HHA care plan dated 2/19/23, revealed the HHA was to provide personal care services of bed bath, shampooing hair, oral care, skin care, pericare, emptying catheter drainage bag, turning and positioning every visit; and homemaking tasks of making the bed and changing the linen at every visit. Review of the service documentation completed by HHA #3 between 6/20/23 to 7/25/23 revealed HHA #3 documented she had provided dressing assistance, hair care and emptying the catheter bag; which were not on the care plan to complete on the following 10 dates: 6/20/23, 6/22/23, 6/27/23, 6/29/23, 7/3/23, 7/6/23, 7/11/23, 7/13/23, 7/18/23 and 7/20/23. Further review of the documentation revealed HHA #3 failed to provide linen change service which was listed to completed on the care plan on the following 10 dates: 6/20/23, 6/22/23, 6/27/23, 6/29/23, 7/3/23, 7/6/23, 7/11/23, 7/13/23, 7/18/23 and 7/20/23. During an interview on 7/27/23 at approximately 9:30 a.m., HHA #3 stated linen changes were no longer needed as the family was providing this assistance. HHA #3 stated dressing assistance, hair care and catheter care (which included cleaning the tubing) were completed per patient request. HHA #3 stated she could not recall when she had stopped providing linen changes or if she had notified RN #5 of the changes in the care plan. During an interview on 8/1/23 at approximately 3:00 p.m., RN #5 stated she had been aware HHA #3 was providing dressing, incontinence care, hair care and catheter care; however, had not realized these tasks were not listed on the care plan. Further, RN #5 stated she reviewed the HHA documentation against the HHA care plan during all supervisory visits and stated she needed to be more detailed in her review. 3. The clinical record for Patient #7 was reviewed on 7/26/23. The POC for the certification period dated 6/25/23 to 8/23/23 revealed a start of care date of 12/27/22; diagnosis included acute embolism and thrombosis of right femoral vein, acute combined systolic and diastolic heart failure, rheumatoid arthritis, chronic respiratory failure with hypoxia, chronic kidney disease, rheumatic mitral stenosis and legal blindness. The POC orders included SN one to three times per two weeks for nine weeks for ongoing assessment, disease process education and symptom management; and HHA four times a week for nine weeks for assistance with personal care and ADL. a. The HHA failed to provide services in accordance with the plan of care for Patient #7. Review of the HHA care plan, dated 4/25/23 and 6/24/23 with no changes between the care plans, revealed the HHA was to provide personal care services of shower with chair, shampoo hair, hair care, skin care, assist with dressing, medication reminders and assistance with transfers and mobility every visit; and homemaking services of making the bed, light housekeeping and meal set-up every visit. Review of service documentation between 5/1/23 and 7/25/23 revealed HHA #3 provided toileting assistance, which was not noted on the care plan to complete, on the following three dates: 6/25/23, 6/30/23 and 7/1/23. Additionally, HHA #3 provided oral care, which was not noted on the care plan to be completed, on 6/30/23 and 7/1/23. Further review of the service documentation failed to reveal documentation after 7/1/23 by HHA #3 or another HHA and the record failed to reveal notification to RN #5 regarding the change in plan of care or needs of Patient #7. During an interview on 8/1/23 at 2:03 p.m., HHA #3 stated Patient #7 had transitioned to an assisted living facility and therefore no longer needed HHA services after 7/1/23 and RN #5 had been aware of this change. HHA #3 further stated she provided additional services to Patient #7 as she had been experiencing a decline in care and had required more hands-on assistance prior to the move to assisted living. HHA #3 further stated she had not reviewed the HHA care plan in quite some time, to know what had been listed on the care plan to complete. During an interview on 8/1/23 at 3:15 p.m., RN #5 stated she had been aware Patient #7 required additional cueing and oversight due to decline; however, had not been aware HHA #3 had been providing hand-on services which were not care planned. RN #5 stated she had been aware of Patient #7's move to an assisted living and no longer required HHA services after 7/1/23; RN #5 revealed a physician order for HHA discharge from 7/3/23 which had not been signed by RN #5 until 7/30/23. 4. During an interview on 8/2/23 at approximately 1:30 p.m., the administrator stated the RN was responsible for oversight of the HHA care plan and services provided by the HHA. The administrator acknowledged the HHA services provided needed to be in accordance with the HHA care plan, which was expected to be recreated by the RN case manager at every recertification assessment. The administrator further stated she had been overwhelmed by the quality assurance needs of the agency since she no longer had assistance from a quality assurance personnel and had missed these concerns within the records reviewed who had HHA services.

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 the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.105, ORGANIZATION AND ADMINISTRATION OF SERVICES was out of compliance. A total of 10 clinical records were reviewed for compliance with the Condition and Standards of Organization and Administration of Services. Record review revealed a pattern of failures in regard to the home health agency ensuring care and services provided met the patient's needs. Record review revealed the agency's administration failed to ensure the agency organized, managed and administered resources to attain and maintain the highest practicable functional capacity involved in operations of care planning, coordination and quality of care for patients. The agency failed to ensure its administration maintained ongoing quality assessment reviews of the agency's operations to ensure the agency was compliant and progressive in identifying and resolving concerns across the agency. These failures had the potential to affect all patients served by the home health agency. The following standard level deficiencies were also cited: G944- Standard: Administrator must- Based on record review and interview, the administrator failed to ensure the day to day operations of the agency were conducted in accordance with agency policy and regulation. Specifically, the administrator failed to ensure the agency had a functional quality assurance and performance improvement (QAPI) program, care was provided in accordance with the patient plan of care and physician orders, home health aides (HHAs) followed the care plan, comprehensive assessments were completed accurately and timely and updated and revised as needed, treatments and services were provided only as ordered by a physician, all physicians included in patient care were communicated with and all orders were integrated into a complete plan of care. G958- Standard: Clinical manager- Based on record review and interview, the director of nursing (DON), who was also the administrator, failed to ensure the day to day operations of the agency were conducted in accordance with agency policy and regulation. Specifically, the DON failed to ensure the agency had a functional quality assurance and performance improvement (QAPI) program, care was provided in accordance with the patient plan of care and physician orders, home health aides (HHAs) followed the care plan, comprehensive assessments were completed accurately and timely and updated and revised as needed, that treatments and services were provided only as ordered by a physician, all physicians included in patient care were communicated with and all orders were integrated into a complete plan of care.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the administrator failed to ensure the day to day operations of the agency were conducted in accordance with agency policy and regulation. Specifically, the administrator failed to ensure the agency had a functional quality assurance and performance improvement (QAPI) program, care was provided in accordance with the patient plan of care and physician orders, home health aides (HHAs) followed the care plan, comprehensive assessments were completed accurately and timely and updated and revised as needed, treatments and services were provided only as ordered by a physician, all physicians included in patient care were communicated with and all orders were integrated into a complete plan of care. Findings Include: 1. The administrator failed to implement a QAPI which evaluated all agency services and complied with the requirements and standards set forth in Code of Federal Regulations 484.65. During an interview on 7/27/23 at 3:30 p.m., the administrator and the alternate administrator stated the current QAPI identified performance improvement projects (PIPs) related to face to face documentation by the physician was maintained within the records and this issue had been identified related to billing concerns without this documentation and that this concern has been improving because billing had improved. The administrator and alternate administrator stated the other current PIP at the agency included ensuring patient wounds were measured and documented within the record weekly; however, this had not been determined utilizing data and was something the agency administration thought was important. The administrator and alternate administrator acknowledged this was not clearly documented within the QAPI program and included failures to document the severity and frequency of the concerns, corrective measures for improvement, goal completion dates and any information related to monitoring improvements utilizing data. During further interview, the administrator stated that as clinicians completed documentation and added the documentation into the electronic medical record (EMR), the administrator reviewed the clinician's notes as quality assurance daily; however, had not completed review of clinician documentation regarding timeliness or accuracy in review of completion. During further interview on 7/27/23 at 3:55 p.m., the administrator stated the agency QAPI program aimed to ensure patient outcomes were improving which was reviewed within clinician notes and the administrator was tracking mentally; however, had not written down improvements or noted concerns during quality assurance review of clinician documentation daily. The administrator stated there had been a QAPI designated personnel who left in February 2023 and the administrator had overseen QAPI since then. The administrator acknowledged the agency was overdue for a quarterly QAPI meeting regarding services provided between April and June 2023. Cross Reference G640 2. The administrator failed to ensure that HHA's provided services in accordance with the patient care plan in 3 of 3 patients who received HHA services (Patients #1, #5 and #7). During an interview on 8/2/23 at approximately 1:30 p.m., the administrator stated the registered nurse (RN) was responsible for oversight of the HHA care plan and services provided by the HHA. The administrator acknowledged the HHA services provided needed to be in accordance with the HHA care plan, which was expected to be recreated by the RN case manager at every recertification assessment. The administrator further stated she had been overwhelmed by the quality assurance needs of the agency since she no longer had assistance from quality assurance personnel and had missed these concerns within the records reviewed who had HHA services. Cross Reference G800 3. The administrator failed to ensure an initial assessment was provided within 48 hours of referral by a physician for 2 of 10 patients reviewed (Patients #2 and #10). During an interview on 8/2/23 at 1:48 p.m., the administrator stated she could not recall specifically why Patient #2 had a delayed start of care, but she vaguely remembered Patient #2 declining services when the agency originally reached out to schedule the start of care appointment. The administrator stated Patient #2's daughter-in-law reached out to the agency and also asked to be present during the start of care assessment as another possible reason Patient #2's start of care was delayed. The administrator acknowledged the agency failed to document why Patient #2's start of care was delayed and failed to notify and receive a delayed start of care order from Patient #2's primary care physician (PCP). During an interview on 8/2/23 at 2:34 p.m., the administrator stated the handwritten note on Patient #10's 2/27/23 referral document which stated skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) as disciplines to assess Patient #10 was the administrator's handwriting. The administrator stated Patient #10's wife requested SN and OT in addition to PT services and the administrator called Patient #10's PCP and received a verbal order to have all three disciplines assess Patient #10. The administrator acknowledged she failed to document this verbal order. Additionally, the administrator acknowledged SN #8 completed her start of care assessment late, the agency failed to document why this start of care assessment was not completed within 48 hours of receipt of the referral as required by regulation and failed to obtain a delayed start of care order in a timely manner. The administrator stated the agency's electronic medical record did not track much information, including when a referral was received compared to when the patient received their start of care assessment. Thus, the administrator tracked this information manually and struggled to keep track of all referrals and when start of care assessments were completed. Cross Reference G514 4. The administrator failed to ensure an accurate comprehensive assessment was completed in 2 of 2 patients reviewed who had their comprehensive assessments completed by a therapist (Patients #2 and #10). During an interview on 8/2/23 at 4:00 p.m., the administrator acknowledged Patients #2's and #10's comprehensive assessments completed by OT #4 and PT #9 respectively were inaccurate. The administrator stated prior to a few months ago, only SN completed start of care assessments of patients. However, to reduce the SNs workload, the agency began having the OT and PTs complete the start of care comprehensive assessments. The administrator stated she educated OT #4 and PT #9 how to complete the start of care assessment, but acknowledged all members of her care team would benefit from re-education on how to accurately complete start of care assessments. The administrator stated, since her quality assurance (QA) nurse retired in February 2023, she had been responsible, with occasional assistance from the alternate administrator, for the QA tasks of the agency including reviewing comprehensive assessments for accuracy. The administrator acknowledged the agency's current QA process was not effective and the administrator planned to share some of these responsibilities more with the alternate administrator and SN #14, as she understood the importance of having an accurate comprehensive assessment. Cross Reference G526 5. The administrator failed to ensure a complete comprehensive assessment was updated and revised, including the administration of the Outcome and Assessment Information Set (OASIS) within 48 hours of the patient's return home from a hospital admission of 24 hours or more, for 1 of 2 patients reviewed who had returned home following a hospitalization (Patient #1). During an interview on 8/2/23 at 3:50 p.m., the administrator acknowledged SN #5 had been advised to not complete a comprehensive assessment with Patient #1 upon her return home from the hospital on 6/3/23. The administrator stated an updated comprehensive assessment was not required if a patient only stayed in the hospital a day or two and/or if the patient was only in observation in the hospital. The administrator acknowledged Patient #1 sustained fractures to both of her femurs from her fall from bed on 6/1/23 and this was a significant change in Patient #1's health status, which would necessitate a SN complete an updated comprehensive assessment. Cross Reference G548 6. The administrator failed to ensure each patient's plan of care (POC) included all medications, interventions, equipment, goals, and/or types of services and treatments for 6 of 10 patients reviewed (Patients #1, #2, #6, #8, #9 and #10). During an interview on 8/2/23 at 3:12 p.m., the administrator reviewed Patient #2's POC for the certification period dated 6/16/23 to 8/14/23 and agreed the certification period was inaccurate as Patient #2's start of care date was 6/20/23. The administrator could not state why the POC certification dates were inaccurately entered on the POC. During an interview on 8/2/23 at 3:07 p.m., the administrator stated Administrative Assistant #11 entered the first two diagnoses into the agency's electronic medical record (EMR), but the clinician completing the POC was to add any other diagnosis that pertained to the care of the patient on the POC. The administrator acknowledged OT #4 failed to add all diagnoses Patient #2 received care for, to her POC. During an interview on 8/2/23 at 3:09 p.m., the administrator stated OT #4 failed to ensure Patient #2's POC had all required items per regulation. The administrator stated the agency recently started to delegate starts of care to the OTs and PTs and the POC for Patient #2 was one of the first POCs OT #4 had completed. During an interview on 8/2/23 at 3:13 p.m., the administrator acknowledged the start of care date for Patient #9 was inaccurate on both POCs reviewed. The administrator stated she did not know how this was missed in the agency quality assurance review process. During an interview on 7/26/2323 at 10:16 a.m., the administrator stated she and the alternate administrator were responsible for reviewing agency paperwork for accuracy/QA. The administrator stated the agency had another SN who primarily completed the review of documentation for accuracy, but she retired a few months ago. During an interview on 8/2/23 at 1:15 p.m., the administrator acknowledged Patients #1, #2, #6, #8, #9 and #10 POCs were inaccurate. The administrator stated prior to a few months ago, only SNs completed start of care assessments and POC for patients. However, to reduce the SNs workload, the agency began having the OT and PTs complete the start of care assessments. The administrator stated she educated OT #4 and PT #9 how to complete the start of care assessment and corresponding agency POC, but acknowledged all members of her care team would benefit from re-education on how to accurately complete and document a POC. The administrator stated, since her QA nurse retired in February 2023, she had been responsible, with occasional assistance from the alternate administrator, for the QA tasks of the agency including reviewing POCs for accuracy prior to sending the POCs to a patient's physician for review and signature. The administrator acknowledged the agency's current QA process was not effective and the administrator planned to share some of these responsibilities with the alternate administrator and SN #14 as she understood the importance of having an accurate and complete POC for each patient for each certification period. Cross Reference G574 7. The administrator failed to ensure services were provided in accordance with physician's orders for 5 of 10 patients reviewed (Patients #1, #5, #6, #7 and #10). During an interview on 8/2/23 at 1:34 p.m, the administrator stated ST evaluation and treatment was ordered due to Patient #1 struggling to eat. The administrator stated after the ST evaluation and treatment verbal order was received by SN #5, SN #5 informed the administrator Patient #1's struggle to eat was resolved by a dentist and a ST evaluation was no longer necessary. The administrator also stated Patient #1 lived out of the geographical region served by ST #4. When the agency received ST orders out of the geographical region served by ST #4, the agency would refer the patient to another home health care agency for ST. The administrator acknowledged Patient #1's clinical record failed to have documentation of the reason for the ST evaluation, communication with the ST regarding this order, the reason a ST evaluation was no longer necessary, a discharge order for ST, or if the family was informed of another home health care agency who could assist Patient #1 with her ST needs. During an interview on 8/2/23 at 2:47 p.m., the administrator stated the agency expected clinicians to document verbal orders they received from physicians within three to five days of receipt of the order. The administrator acknowledged the discharge HHA verbal order written by SN #5 29 days after receipt of the order was not timely. The administrator stated she would re-educate all SNs and therapists on the agency's expectation to write timely verbal orders and to communicate with physicians in a timely manner. During an interview on 8/2/23 at 1:34 p.m. the administrator stated she and/or the alternate administrator informed therapists of therapy orders received for a patient. The administrator stated the agency tracked these referral therapy orders and which therapist the agency assigned, to ensure therapy evaluations were completed as ordered. The administrator stated if a therapy order was received by a SN, typically the SN would communicate these orders to the therapist. The administrator stated SN #5 struggled with remembering to inform therapists of evaluation orders she received more than the other two SNs at the agency (SNs #8 and #13) as SN #5 had another job. The administrator acknowledged the agency's system of tracking referral orders and who the agency assigned to complete the order was not working nor documented in the patient's clinical record. During an interview on 8/2/23 at 2:42 p.m., the administrator stated each clinician was responsible for tracking visit frequency and the agency expected all disciplines providing care to a patient to document a missed visit with the reason the visit was missed if they were unable to complete a visit as scheduled. The agency's EMR tracked all documented missed visits; the agency administrator ran a missed visit report each week; and the administrator faxed the missed visits to each patient's PCP respectively. If a clinician failed to document a missed visit, the administrator would not be alerted if a missed visit occurred as the agency's EMR did not track undocumented missed visits. Cross Reference G578 8. The administrator failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 7 active patients reviewed (Patient #5). During an interview on 8/2/23 at 2:05 p.m., the administrator stated the agency received a phone call from Patient #5's PCP ordering the agency to start skilled services including SN, PT, OT, and HHA for Patient #5 prior to the agency receiving the order on 6/9/23. The administrator acknowledged the agency failed to document this conversation with Patient #5's PCP and a verbal order was not documented for start of care orders for Patient #5 on 6/5/23. During an interview on 8/2/23 at 2:15 p.m., the administrator acknowledged the agency failed to obtain a verbal order for SN and HHA visits provided to Patient #5 from her start of care on 6/5/23 until Patient #5's PCP signed Patient #5's plan of care on 7/5/23. The administrator stated she would re-educate SN #5 on the regulation which required all services and treatment be provided only as ordered by a physician and the need to obtain a verbal order for services and treatment provided prior to a patient's PCP signing a patient's plan of care. During an interview on 8/2/23 at 2:10 p.m., the administrator reviewed Patient #5's clinical record including her orders and acknowledged SN #5 failed to obtain orders for all of the wound care she provided. The administrator stated SN #5 should not have assumed orders she obtained for her left leg, left arm and right hand skin tears applied to the two wounds SN #5 treated on Patient #5's right leg. The administrator stated the agency expectation was any time there was a change in a patient's need from their plan of care orders, the SN or therapist was expected to call the patient's physician to obtain an interim order to provide the care the patient required and to document this order as a verbal order in the patient's clinical record. Cross Reference G580 9. The administrator failed to ensure communication with all physicians involved in the plan of care; failed to integrate orders to ensure the coordination of all services and interventions provided to the patient; and failed to coordinate care delivery to meet patient's needs for 6 of 10 patients reviewed (Patients #1, #2, #5, #6, #8, and #10). During an interview on 8/2/23 at 2:34 p.m., the administrator stated the handwritten note on Patient #10's 2/27/23 referral document which stated SN, PT and OT as disciplines to assess Patient #10 was the administrator's handwriting. The administrator confirmed either she or the alternate administrator coordinated with all disciplines when they had evaluation orders for a patient to ensure the discipline was made aware of the order, scheduled the visit and completed the ordered assessment. The administrator stated she could not recall why OT did not complete an evaluation with Patient #10 and acknowledged the clinical record failed to state why Patient #10 did not receive an OT evaluation. During an interview on 8/2/23 at 1:53 p.m., the administrator stated the agency expected each discipline to call a patient's PCP to inform him/her if the patient declined further care from a discipline and to obtain an order to discharge their service. The administrator acknowledged OT #4 failed to coordinate this care with Patient #2's PCP. The administrator stated she was responsible for monitoring patient charts to ensure all appropriate orders and care coordination occurred and she did not know why this lack of care coordination was missed during the administrator's QA review process. During an interview on 8/2/23 at 1:22 p.m., the administrator stated the agency expected the SN overseeing a patient's care to coordinate a patient's care with the patient's PCP including communicating with the PCP if a patient requested to have an ordered service discharged. The administrator stated SN #5 should have contacted Patient #5's PCP to inform him Patient #5 no longer desired HHA services. The administrator stated she attempted to monitor patients records and catch when a patient had missing orders, but she struggled to keep up with all of her responsibilities. During an interview on 8/2/23 at 1:25 p.m., the administrator stated prior to February 2023, the agency had a QA nurse who assisted the administrator and the alternate administrator with tracking if care coordination occurred appropriately including ensuring physician orders were obtained for all treatments and disciplines, ensuring all orders were completed, and clinicians were writing accurate and complete care coordination notes. The administrator stated, since the QA nurse who performed these tasks retired in February 2023, the responsibility fell to the administrator, and the alternate administrator assisted her when she could. The administrator stated she did not have enough time to keep up with all of her job responsibilities and many tasks were not completed as required by regulation or agency expectation. The administrator stated she planned to assign some of the QA duties to SN #14 to assist the agency to get back in compliance with regulations and agency expectations. Cross Reference G600

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the director of nursing (DON), who was also the administrator, failed to ensure the day to day operations of the agency were conducted in accordance with agency policy and regulation. Specifically, the DON failed to ensure the agency had a functional quality assurance and performance improvement (QAPI) program, care was provided in accordance with the patient plan of care and physician orders, home health aides (HHAs) followed the care plan, comprehensive assessments were completed accurately and timely and updated and revised as needed, treatments and services were provided only as ordered by a physician, all physicians included in patient care were communicated with and all orders were integrated into a complete plan of care. Findings Include: 1. The DON failed to implement a QAPI which evaluated all agency services and complied with the requirements and standards set forth in Code of Federal Regulations 484.65. During an interview on 7/27/23 at 3:30 p.m., the DON/administrator and the alternate administrator stated the current QAPI identified performance improvement projects (PIPs) related to face to face documentation by the physician was maintained within the records and this issue had been identified related to billing concerns without this documentation and that this concern had been improving because billing has improved. The DON/administrator and alternate administrator stated the other current PIP at the agency included ensuring patient wounds were measured and documented within the record weekly; however, this had not been determined utilizing data and was something the agency administration thought was important. The DON/administrator and alternate administrator acknowledged this was not clearly documented within the QAPI program and included failures to document the severity and frequency of the concerns, corrective measures for improvement, goal completion dates and any information related to monitoring improvements utilizing data. During further interview, the DON stated that as clinicians completed documentation and added the documentation into the electronic medical record (EMR), the administrator reviewed the clinician's notes as quality assurance (QA) daily; however, had not completed review of clinician documentation regarding timeliness or accuracy in review of completion. During further review on 7/27/23 at 3:55 p.m., the DON stated the agency QAPI program aimed to ensure patient outcomes were improving which was reviewed within clinician notes and the administrator is tracking mentally; however, had not written down improvements or noted concerns during QA review of clinician documentation daily. The DON stated there had been a QAPI designated personnel who had left in February 2023 and the DON had overseen QAPI since then; the DON acknowledged the agency was overdue for a quarterly QAPI meeting regarding services provided between April to June 2023. Cross Reference G640 2. The DON failed to ensure that HHA's provided services in accordance with the patient care plan in 3 of 3 patients who received HHA services (Patients #1, #5 and #7). During an interview on 8/2/23 at approximately 1:30 p.m., the DON stated the registered nurse (RN) was responsible for oversight of the HHA care plan and services provided by the HHA. The DON acknowledged the HHA services provided needed to be in accordance with the HHA care plan, which was expected to be recreated by the RN case manager at every recertification assessment. The administrator further stated she had been overwhelmed by the QA needs of the agency since she no longer had assistance from QA personnel and had missed these concerns within the records reviewed who had HHA services. Cross Reference G800 3. The DON failed to ensure an initial assessment was provided within 48 hours of referral by a physician for 2 of 10 patients reviewed (Patients #2 and #10). During an interview on 8/2/23 at 1:48 p.m., the DON stated she could not recall specifically why Patient #2 had a delayed start of care, but she vaguely remembered Patient #2 declining services when the agency originally reached out to schedule the start of care appointment. The DON stated Patient #2's daughter-in-law reached out to the agency and also asked to be present during the start of care assessment as another possible reason Patient #2's start of care was delayed. The DON acknowledged the agency failed to document why Patient #2's start of care was delayed and failed to notify and receive a delayed start of care order from Patient #2's primary care physician (PCP). During an interview on 8/2/23 at 2:34 p.m., the DON stated the handwritten note on Patient #10's 2/27/23 referral document which stated skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) as disciplines to assess Patient #10 was the DONs handwriting. The DON stated Patient #10's wife requested SN and OT in addition to PT services and the administrator called Patient #10's PCP and received a verbal order to have all three disciplines assess Patient #10. The DON acknowledged she failed to document this verbal order. Additionally, the DON acknowledged SN #8 completed her start of care assessment late, the agency failed to document why this start of care assessment was not completed within 48 hours or receipt of the referral as required by regulation and failed to obtain a delayed start of care order in a timely manner. The DON stated the agency's electronic medical record does not track much information, including when a referral was received compared to when the patient received their start of care assessment. Thus, the DON tracked this information manually and struggled to keep track of all referrals and when start of care assessments were completed. Cross Reference G514 4. The DON failed to ensure an accurate comprehensive assessment was completed in 2 of 2 patients reviewed who had their comprehensive assessments completed by a therapist (Patients #2 and #10). During an interview on 8/2/23 at 4:00 p.m., the DON acknowledged Patients #2's and #10's comprehensive assessments completed by OT #4 and PT #9 respectively were inaccurate. The DON stated prior to a few months ago, only SN completed start of care assessments of patients. However, to reduce the SNs workload, the agency began having the OT and PTs complete the start of care comprehensive assessments. The DON stated she educated OT #4 and PT #9 how to complete the start of care assessment, but acknowledged all members of her care team would benefit from re-education on how to accurately complete start of care assessments. The DON stated since her QA nurse retired in February 2023, she had been responsible, with occasional assistance from the alternate administrator, for the QA tasks of the agency including reviewing comprehensive assessments for accuracy. The DON acknowledged the agency's current QA process was not effective and the DON planned to share some of these responsibilities more with the alternate administrator and SN #14, as she understood the importance of having an accurate comprehensive assessment, for each patient for each certification period. Cross Reference G526 5. The DON failed to ensure a complete comprehensive assessment was updated and revised, including the administration of the Outcome and Assessment Information Set (OASIS) within 48 hours of the patient's return home from a hospital admission of 24 hours or more, for 1 of 2 patients reviewed who had returned home following a hospitalization (Patient #1). During an interview on 8/2/23 at 3:50 p.m., the DON acknowledged SN #5 had been advised to not complete a comprehensive assessment with Patient #1 upon her return home from the hospital on 6/3/23. The DON stated an updated comprehensive assessment was not required if a patient only stayed in the hospital a day or two and/or if the patient was only in observation in the hospital. The DON acknowledged Patient #1 sustained fractures to both of her femurs from her fall from bed on 6/1/23 and this was a significant change in Patient #1's health status, which would necessitate a SN complete an updated comprehensive assessment. Cross Reference G548 6. The DON failed to ensure each patient's plan of care (POC) included all medications, interventions, equipment, goals, and/or types of services and treatments for 6 of 10 patients reviewed (Patients #1, #2, #6, #8, #9 and #10). During an interview on 8/2/23 at 3:12 p.m., the DON reviewed Patient #2's POC for the certification period dated 6/16/23 to 8/14/23 and agreed the certification period was inaccurate as Patient #2's start of care date was 6/20/23. The DON could not state why the POC certification dates were inaccurately entered on the POC. During an interview on 8/2/23 at 3:07 p.m., the DON stated Administrative Assistant #11 entered the first two diagnoses into the agency's electronic medical record (EMR), but the clinician completing the POC was to add any other diagnosis that pertained to the care of the patient on the POC. The DON acknowledged OT #4 failed to add all diagnoses Patient #2 received care for, to her POC. During an interview on 8/2/23 at 3:09 p.m., the DON stated OT #4 failed to ensure Patient #2's POC had all required items per regulation. The DON stated the agency recently started to delegate starts of care to the OTs and PTs and the POC for Patient #2 was one of the first POCs OT #4 had completed. During an interview on 8/2/23 at 3:13 p.m., the DON acknowledged the start of care date for Patient #9 was inaccurate on both POCs reviewed. The administrator stated she did not know how this was missed in the agency quality assurance review process. During an interview on 7/26/2323 at 10:16 a.m., the DON stated she and the alternate administrator were responsible for reviewing agency paperwork for accuracy/QA. The DON stated the agency had another SN who primarily completed the review of documentation for accuracy, but she retired a few months ago. During an interview on 8/2/23 at 1:15 p.m., the DON acknowledged Patients #1, #2, #6, #8, #9 and #10 POCs were inaccurate. The DON stated prior to a few months ago, only SN completed start of care assessments and POC for patients. However, to reduce the SNs workload, the agency began having the OT and PTs complete the start of care assessments. The DON stated she educated OT #4 and PT #9 how to complete the start of care assessment and corresponding agency POC, but acknowledged all members of her care team would benefit from re-education on how to accurately complete and document a POC. The DON stated, since her QA nurse retired in February 2023, she had been responsible, with occasional assistance from the alternate administrator, for the QA tasks of the agency including reviewing POCs for accuracy prior to sending the POCs to a patient's physician for review and signature. The DON acknowledged the agency's current QA process was not effective and the DON planned to share some of these responsibilities more with the alternate administrator and SN #14 as she understood the importance of having an accurate and complete POC for each patient for each certification period. Cross Reference G574 7. The DON failed to ensure services were provided in accordance with physician's orders for 5 of 10 patients reviewed (Patients #1, #5, #6, #7 and #10). During an interview on 8/2/23 at 1:34 p.m, the DON stated speech therapist (ST) evaluation and treatment was ordered due to Patient #1 struggling to eat. The DON stated after the ST evaluation and treatment verbal order was received by SN #5, SN #5 informed the DON Patient #1's struggle to eat was resolved by a dentist and a ST evaluation was no longer necessary. The DON also stated Patient #1 lived out of the geographical region served by ST #4. When the agency received ST orders out of the geographical region served by ST #4, the agency would refer the patient to another home health care agency for ST. The DON acknowledged Patient #1's clinical record failed to have documentation of the reason for the ST evaluation, communication with the ST regarding this order, the reason a ST evaluation was no longer necessary, a discharge order for ST, or if the family was informed of another home health care agency who could assist Patient #1 with her ST needs. During an interview on 8/2/23 at 2:47 p.m., the DON stated the agency expected clinicians to document verbal orders they received from physicians within three to five days of receipt of the order. The DON acknowledged the discharge HHA verbal order written by SN #5 29 days after receipt of the order was not timely. The DON stated she would re-educate all SNs and therapists on the agency's expectation to write timely verbal orders and to communicate with physicians in a timely manner. During an interview on 8/2/23 at 1:34 p.m., the DON stated she and/or the alternate administrator informed therapists of therapy orders received for a patient. The DON stated the agency tracked these referral therapy orders and which therapist the agency assigned, to ensure therapy evaluations were completed as ordered. The DON stated if a therapy order was received by a SN, typically the SN would communicate these orders to the therapist. The DON stated SN #5 struggled with remembering to inform therapists of evaluation orders she received more than the other two SNs at the agency (SNs #8 and #13) as SN #5 had another job. The DON acknowledged the agency's system of tracking referral orders and who the agency assigned to complete the order was not working or documented in the patient's clinical record. During an interview on 8/2/23 at 2:42 p.m., the DON stated each clinician was responsible for tracking visit frequency and the agency expected all disciplines providing care to a patient to document a missed visit with the reason the visit was missed if they are unable to complete a visit as scheduled. The agency's EMR tracked all documented missed visits; the agency administrator ran a missed visit report each week; and the DON faxed the missed visits to each patient's PCP respectively. If a clinician failed to document a missed visit, the administrator would not be alerted if a missed visit occurred as the agency's EMR did not track undocumented missed visits. Cross Reference G578 8. The DON failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 7 active patients reviewed (Patient #5). During an interview on 8/2/23 at 2:05 p.m., the DON stated the agency received a phone call from Patient #5's PCP ordering the agency to start skilled services including SN, PT, OT, and HHA for Patient #5 prior to the agency receiving the order on 6/9/23. The DON acknowledged the agency failed to document this conversation with Patient #5's PCP and a verbal order was not documented for start of care orders for Patient #5 on 6/5/23. During an interview on 8/2/23 at 2:15 p.m., the DON acknowledged the agency failed to obtain a verbal order for SN and HHA visits provided to Patient #5 from her start of care on 6/5/23 until Patient #5's PCP signed Patient #5's plan of care on 7/5/23. The DON stated she would re-educate SN #5 on the regulation which required all services and treatment be provided only as ordered by a physician and the need to obtain a verbal order for services and treatment provided prior to a patient's PCP signing a patient's plan of care. During an interview on 8/2/23 at 2:10 p.m., the DON reviewed Patient #5's clinical record including her orders and acknowledged SN #5 failed to obtain orders for all of the wound care she provided. The DON stated SN #5 should not have assumed orders she obtained for her left leg, left arm and right hand skin tears applied to the two wounds SN #5 treated on Patient #5's right leg. The DON stated the agency expectation was any time there was a change in a patient's need from their plan of care orders, the SN or therapist was expected to call the patient's physician to obtain an interim order to provide the care the patient required and to document this order as a verbal order in the patient's clinical record. Cross Reference G580 9. The DON failed to ensure communication with all physicians involved in the plan of care; failed to integrate orders to ensure the coordination of all services and interventions provided to the patient; and failed to coordinate care delivery to meet patient's needs for 6 of 10 patients reviewed (Patients #1, #2, #5, #6, #8, and #10). During an interview on 8/2/23 at 2:34 p.m., the DON stated the handwritten note on Patient #10's 2/27/23 referral document which stated SN, PT and OT as disciplines to assess Patient #10 was the administrator's handwriting. The DON confirmed either she or the alternate administrator coordinated with all disciplines when they had evaluation orders for a patient to ensure the discipline was made aware of the order, scheduled the visit and completed the ordered assessment. The DON stated she could not recall why OT did not complete an evaluation with Patient #10 and acknowledged the clinical record failed to state why Patient #10 did not receive an OT evaluation. During an interview on 8/2/23 at 1:53 p.m., the DON stated the agency expected each discipline to call a patient's PCP to inform him/her if the patient declined further care from a discipline and to obtain an order to discharge their service. The DON acknowledged OT #4 failed to coordinate this care with Patient #2's PCP. The DON stated she was responsible for monitoring patient charts to ensure all appropriate orders and care coordination occurred and she did not know why this lack of care coordination was missed during the administrator's quality assurance (QA) review process. During an interview on 8/2/23 at 1:22 p.m., the DON stated the agency expected the SN overseeing a patient's care to coordinate a patient's care with the patient's PCP including communicating with the PCP if a patient requested to have an ordered service discharged. The DON stated SN #5 should have contacted Patient #5's PCP to inform him Patient #5 no longer desired HHA services. The DON stated she attempted to monitor patients records and catch when a patient had missing orders, but she struggled to keep up with all of her responsibilities. During an interview on 8/2/23 at 1:25 p.m., the DON stated prior to February 2023, the agency had a QA nurse who assisted the DON and the alternate administrator with tracking if care coordination occurred appropriately including ensuring physician orders were obtained for all treatments and disciplines, ensuring all orders were completed, and clinicians were writing accurate and complete care coordination notes. The DON stated, since the QA nurse who performed these tasks retired in February 2023, the responsibility fell to the administrator, and the alternate administrator assisted her when she could. The DON stated she did not have enough time to keep up with all of her job responsibilities and many tasks were not completed as required by regulation or agency expectation. The DON stated she planned to assign some of the QA duties to SN #14 to assist the agency to get back in compliance with regulations and agency expectations. Cross Reference G600