Every finding on record at Home Health Specialty Services, Inc

Unannounced visits were concluded at Home Health Specialty Services, Inc. on 7/24/24 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). Standard level deficiencies were identified.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency Emergency Preparedness Plan, the agency failed to identify the scheduling and completion of a review of the agency Emergency Preparedness risk assessment and response plan, and failed to identify the participation in an annual testing exercise, including the inclusion of a full scale exercise every 2 years, during the calendar years 2022 and 2023. Review of the the agency Emergency Preparedness Plan with the Administrator on 7/24/24 at 11:00am, failed to identify the scheduling and completion of an agency specific and/or participation in a municipal sponsored tabletop exercise that included a group discussion using a narrative , clinically relevant emergency scenarios, and problem statements with resolutions, along with documentation of tabletop exercises summary.

Unannounced visits concluded at Home Health Specialty Services, Inc. on 7/24/24 for the purpose of a Federal recertification. Standard level deficiencies were identified.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on an onsite observations, interview with agency personnel, and review of agency policy, for one (1) of five (5) patients (Patient #4), receiving skilled nursing services, the agency personnel failed to utilize accepted infection control practice techniques during a nursing visit. The findings include. Patient # 4 had a start of care date to the home care agency on 4/7/23, with diagnoses that included Diabetes Mellitus -Type II, Hypertension, Dysphagia, Epilepsy, Traumatic Brain Injury (TBI), with forgetfulness. Review of the physician orders for certification period dated 5/31/24 through 7/29/24 identified skilled nursing visits daily (7 days a week) for eight weeks, and 2 times for 1 week, for daily medication administration, general health evaluation, reinforcement of diabetic education, blood glucose monitoring, weekly medication pre-pour for evening medication self administration by patient, and diet compliance education. During a joint onsite home nursing visit with Registered Nurse (RN #1) on 7/23/24 at 8:15am, medication administration, weekly evening medication pre-pour, and a nursing health evaluation visit, the surveyor observed RN #1 perform a blood pressure evaluation utilizing a blood pressure cuff and stethoscope from her agency nursing bag, but failed to identify RN #1 cleaned/disinfected the equipment at the completion of the patient evaluation before replacing it in her agency nursing bag. Interview with the agency Supervisor of Clinical Services (SCS) and the agency Administrator (Admin.) on 7/24/24 at 11:00am, identified all direct care staff complete onboard and annual training that includes education and updates on the agency infection control practices, and proper nursing bag technique, but failed to identify that RN #1 followed the agency policy on Nursing Bag technique. Review of the agency policy for Nursing Bag Technique, identified all agency visiting home health providers will utilize proper nursing bag technique. All visiting home health providers that have utilized reusable equipment, including a blood pressure cuff, and stethoscope etc., must be cleaned with 70% isopropyl alcohol before returning to the bag.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency documentation, review of agency policy, and interview with agency personnel, for one (1) of five (5) patients (Patient #4), receiving daily medication administration and weekly medication pre pour from the agency, the agency personnel failed to monitor, evaluate and supervise the Registered Nurse staff, in the delivery of skilled nursing services. The findings include. Patient # 4 had a start of care date to the home care agency on 4/7/23, with diagnoses that included Diabetes Mellitus -Type II, Hypertension, Dysphagia, Epilepsy, Traumatic Brain Injury (TBI), with Forgetfulness. Review of the physician orders for certification period dated 5/31/24 through 7/29/24 identified skilled nursing visits daily (7 days a week) for eight weeks and 2 times for 1 week, for daily medication administration, general health evaluation, reinforcement of diabetic education, and blood glucose monitoring, weekly medication pre-pour for evening medication self-administration by patient, and diabetic diet compliance. During a joint home nursing visit with Registered Nurse (RN#1) on 7/23/24 at 8:15am, for medication administration, medication pre-pour, and a nursing health evaluation. The surveyor observed LPN #1 perform a blood pressure evaluation, removing and utilizing a blood pressure cuff and stethoscope from her agency nursing bag, but failed to identify RN #1 cleaned/disinfected the equipment at the completion of the evaluation for patient, before replacing it in her agency nursing bag. During the same joint onsite visit with RN #1 on 7/23/24, the surveyor observed the nurse prepare the morning oral medications, including an injectable medication syringe of Insulin Glargine (Lantus Solostar) 100units/ml (per milliliter) 20 units for administration, without the use of a paper and/or electronic medication administration record (MAR). While RN #1 was preparing Patient #1's, she turned to this surveyor and said, " I have memorized all his meds, I've done them for so long". Interview with the agency Supervisor of Clinical Services (SCS) and the Administrator (Admin.) on 7/24/24 at 11:00am, identified all direct care staff complete onboarding and annual training that includes education and updates on the agency infection control practices, including proper nursing bag technique, and medication profile reconciliation, medication administration and medication pre-pour techniques, along with the corresponding policy reviews. The SCS identified that all staff are expected to clean/disinfect any equipment at the completion of a task, before being stored in the nursing bag. The SCS further identified that all care providers are supplied with computer tablets, for use during each home visits. Medication profile reconciliation, new medication order verification and review of the patient's medication administration record (MAR) are to be completed at every nursing visit, per agency policy, but failed to identify the monitoring and evaluation of the RN’s performance in the provision of services, treatments and care, and adherence to the agency policies. Review of the agency policy for Nursing Bag Technique, identified all agency visiting home health providers will utilize proper nursing bag technique. All visiting home health providers that have utilized reusable equipment, including a blood pressure cuff, and stethoscope etc., must be cleaned with 70% isopropyl alcohol before returning to the bag. Review of the agency policy on medication administration identified that medication will be administered only per the order of a physician, and the medication profile must be reconciled at each visit.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency documentation, observation, review of agency policy and interviews with agency personnel, for one (1) of five (5) patients (Patient #4), the agency failed to ensure that care delivered was in accordance to the physician ordered plan of care, in accordance to the agency policy. The findings include. Patient # 4 had a start of care date to the home care agency on 4/7/23, with diagnoses that included Diabetes Mellitus -Type II, Hypertension, Dysphagia, Epilepsy, Traumatic Brain Injury (TBI), with forgetfulness. Review of the physician orders for certification period dated 5/31/24 through 7/29/24 identified skilled nursing visits daily ( 7 days a week) for eight weeks and 2 times for 1 week, for daily medication administration, general health evaluation, reinforcement of diabetic education, and blood glucose monitoring, weekly medication pre-pour for evening medication self administration by patient, and diet compliance, During a joint onsite home nursing visit with Registered Nurse (RN #1) on 7/23/24 at 8:15am, for medication administration, medication pre-pour, and a nursing health evaluation. The surveyor observed RN #1 perform a medication administration and weekly pre pour of the patient's evening self administered medications, but failed to identify RN #1 reconciled the patient's medications, or utilized a written or computerized medication list for the morning medication administration, and for the evening medication pre pour. Interview with agency Supervisor of Clinical Services (SCS) and the Administrator (Admin.) on 7/24/24 at 11:00am, identified all direct care staff complete onboard and annual training that includes education and updates on the agency policy for medication administration and medication pre pours. The SCS further identified that all care providers are supplied with computer tablets, for use during each home visits for medication reconciliation, order verification and review of the patient's medication administration record (MAR) during a medication administration and medication pre-pour, per agency policy, but failed to identify the monitoring and evaluation of the RN’s performance in the provision of services, treatments and care, and adherence to the agency policies. Review of the agency policy on Medication Administration identified that medication will be administered only per the order of a physician, and the medication profile must be reconciled at each visit.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the agency documentation and interview with agency personnel, the home health agency failed to ensure to review and revise of the Emergency Preparedness Plan (EPP) to reflect current CMS (Center for Medicare and Medicaid Services) Emergency Preparedness requirements. The findings include: Interview and review of the Emergency Preparedness Plan dated 10/10/2017 with the Administrator on 8/4/2021 at 11:00 AM identified that the EPP was last reviewed and revised in 2017, the Administrator was unaware of the current CMS requirements and failed to identify the revision of the EPP since 2017 to reflect the changes made by CMS in 2019 (The agency must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years).

Unannounced visits were concluded at Home Health Specialty Services Inc. on 8/04/2021 for the purpose of recertification, re-licensure and investigating CT # 30459. Standard-level deficiencies were identified.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review and interview with the agency personnel for four of four patient's (Patients #1, #3, #8 and #11) who required wound care, the agency professionals failed to ensure weekly wound measurements were conducted in accordance with the agency policy and for four of eleven patients (Patient #3, #4, #8 and #11) in the survey sample, the agency Registered Nurses (RN) failed to ensure monthly supervision of the Licensed Practical Nurses (LPNs). The findings include: 1. Patient #1 had a start of care date of 1/06/2020 and diagnoses that included stage IV pressure ulcer of the left buttock and stage II pressure ulcer of the sacrum. The physician's orders for the certification period of 6/29/21 to 8/27/21 included nursing services 2 times a week for assessments and wound care to the sacrum and left buttock. a. Interview and review of the nursing notes from 6/29/21 to 8/27/21 with the SCS on 8/04/21 at 11 AM failed to identify weekly wound measurements for the weeks of 7/11/21 to 7/17/21 and 7/25/21 to 7/31/21. Agency policy for Wound Care directed the measurement of wounds weekly. 2. Patient #3 had a start of care date of 10/08/2021 with diagnoses that included a stage IV pressure ulceration of the sacral region, type II diabetes mellitus and paraplegia. The physician's orders for the certification period dated 12/07/2020 to 02/05/2021 included nursing services 3 times per week for 9 weeks for assessments and to provide wound care. The physician's orders for the certification period dated 06/05/2021 to 08/03/2021 included nursing services 2 times per week for 9 weeks for assessments and to provide wound care. a. Interview and review of Patient #3's nursing notes from 12/07/2020 to 02/05/2021 with the Supervisor of Clinical Services (SCS) on 08/03/2021 at 12:00 PM, failed to identify weekly wound measurements for the weeks of 12/20/2020, 12/27/2020, 01/03/2021, 01/10/2021, 01/17/2021 and 01/24/2021. Furthermore, a review of Patient #3's nursing notes from 06/05/2021 to 08/03/2021 (9 weeks) with the SCS, identified that 8 out of 15 visits were completed by an Licensed Practical Nurse (LPN) but failed to identify monthly supervision of the LPN documented by the Registered Nurse (RN) in the clinical record. 3. Patient #4 had a start of care date of 5/26/21 and diagnoses that included schizoaffective disorder, intellectual disabilities and epilepsy. The physician's orders dated 5/26/21 included nursing services 7 times a week for assessments, daily medication administration and pre-poring of evening medications. b. Interview and review of the nursing notes from 5/26/21 to 7/22/21 (8 weeks) with the Supervisor of Clinical Services (SCS) on 8/04/21 at 10 AM identified that 56 out of 58 visits were completed by LPN's but failed to identify monthly supervision of the LPN's documented by the RN in the clinical record. 4. Patient #8 had a start of care date of 10/27/20 and diagnoses that included a stage III pressure ulcer of the left heel, type II diabetes mellitus and chronic kidney disease, stage 3 and placement of Foley catheter. The physician's orders dated 5/4/21 included nursing services three times a week for 8 weeks to provide wound care to the patient's stage III pressure ulcer to the left heel. The wound care orders directed to clean wound with normal saline, Aquacel Alginate, cover with 4x4 gauze, wrap with kerlix and secure with a tape by using aseptic technique. On 4/21/21, for the recertification assessment, RN#2 documented that the patient had a stage III pressure ulcer to the left heel measuring 4 x 3 x 0.2 centimeters (cm), pink wound bed, moderate amount of serosanguineous drainage and no odor. Physician order dated 5/31/21 directed to decrease nursing services to once a month for Foley catheter assessment and management. On 6/4/21, LPN#4 documented the wound care to be performed by the physician and the bandage not to be removed. Patient#8 was discharged from the agency on 6/17/21. The discharge summary dated 6/17/21 identified that patient's wound healed. a.Interview and review of the nursing notes from 4/27/21 through 5/26/21with the Supervisor of Clinical Services/SCS on 8/4/21 at 12:50 PM identified nursing visits from that Licensed Practical Nurses #1, 2 & 4 (LPNs) on 4/27/21, 4/29/21, 5/3/21, 5/5/21, 5/7/21, 5/10/21, 5/12/21, 5/14/21, 5/17/21, 5/19/21, 5/21/21, 5/24/21 and 5/26/21 (a total of 13 visits) but failed to identify weekly wound measurements in accordance with the agency policy. b.Interview and review of the nursing notes from 4/27/21 through 5/26/21with the Supervisor of Clinical Services/SCS on 8/4/21 at 12:50 PM identified that nursing visits were completed by LPNs on 4/27/21, 4/29/21, 5/3/21, 5/5/21, 5/7/21, 5/10/21, 5/12/21, 5/14/21, 5/17/21, 5/19/21, 5/21/21, 5/24/21 and 5/26/21 ( a total of 13 visits) and failed to identify monthly supervision of the LPNs documented by the Registered Nurse (RN) in the clinical record in accordance with the agency policy. 5. Patient #11 had a start of care date of 06/28/2021 with diagnoses that included chronic ulcers to lower legs, peripheral vascular disease and left femur fracture. The physician's orders dated 06/28/2021 included nursing services 15 times for 1 month for assessments and to provide wound care. a. Interview and review of the nursing notes from 06/28/2021 to 08/02/2021(6 weeks) with the SCS on 08/03/2021 at 12:10 PM, identified that 15 out of 18 visits were completed by an LPN but failed to identify monthly supervision of the LPN documented by the RN in the clinical record and failed to identify weekly wound measurements for the weeks of 07/04/2021 to 07/10/2021 and 07/25/2021 to 07/31/2021. Review of the agency policy for supervision of LPN's directed in part LPN's are supervised monthly by the required personnel with documentation of such supervision made in the clinical record. Review of the agency policy for Wound Care Management, identified documentation of wounds must include type of wound, measurements including length, width and depth. Wound description and measurements are to be completed at the start of care, weekly and with any changes.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and interview with the agency personnel for one of one patient (Patient #10) in a survey sample who required the assessment of the patient's weight and SPO2 (oxygen saturation), the agency nurses failed to provide the necessary assessments. The findings include: Patient #10 had a start of care date of 4/05/21 and diagnoses that included chronic obstructive pulmonary disease and congestive heart failure. The physician's orders for the period of 1/05/21 through 6/3/21 included nursing services 1 time a week for 8 weeks to pre-pour medications, teach and assess for fluid retention, assess weights and report a weight gain greater than 5 pounds per week, and assess SPO2 and report less than 90% to the physician. a. Interview and review of Licensed Practical Nurse (LPN) #2's notes for the period of 4/12/21 through 5/03/21 (a total of 4 visits) with the Supervisor of Clinical Services (SCS) on 8/04/21 at 12:30 PM failed to identify nursing assessment of the patient's weight and SPO2; b. Interview and review of Registered Nurse/RN#2 note dated 5/12/21 with SCS #1 on 8/4/21 at 12:35 PM failed to identify nursing assessment of the patient's weight and SPO2.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of eleven patients (Patient #1) in the survey sample, the agency professionals failed to follow the physician-certified plan of care. The findings include: Patient #1 had a start of care date of 1/06/2020 and diagnoses that included stage IV pressure ulcer of the left buttock and stage II pressure ulcer of the sacrum. The physician's orders for the certification period of 6/29/21 to 8/27/21 included nursing services 2 times a week for assessments and wound care to the sacrum and left buttock. Interview and review of the nursing notes from 6/29/21 to 8/27/21 with the SCS on 8/04/21 at 11 AM identified only one nursing visit for the weeks of 7/11/21 to 7/17/21 and 7/25/21 to 7/31/21 and failed to identify conformance with the physician's orders for twice weekly nursing visits.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, for one patient (Patient #3) with a diagnosis of a new stage II pressure ulcer and the need for wound care, the agency nurse performed wound care without a physician's order. The findings include: Patient #3 had a start of care date of 10/08/2021 with diagnoses that included a stage IV pressure ulceration of the sacral region, type II diabetes mellitus and paraplegia. The physician's orders for the certification period dated 06/05/2021 to 08/03/2021 included nursing services 2 times per week for 9 weeks for assessments and to provide wound care. Interview and review of Registered Nurse (RN) #2's clinical note dated 07/02/2021 with the Supervisor of Clinical Services (SCS) on 08/03/2021 at 1:00 PM, identified Patient #3 developed a stage II pressure ulcer to the midline lower back observed on 07/02/2021, RN #2 called the wound care clinic during the visit and awaited a return call for wound care orders. RN #2 proceeded to perform wound care to the new stage II pressure ulcer while awaiting a physician's order. Furthermore, a review of Patient #3's clinical record from 07/02/2021 to 08/02/2021, identified RN #2 failed to obtain wound care orders from a physician to treat Patient #3's stage II pressure ulcer. Subsequent to surveyor's inquiry, RN #2 obtained a physician's order on 08/03/2021. Agency policy for Wound Care Management identified all wound care instructions will be ordered by a physician and will be individualized to the patient's specific needs.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on review of the clinical records and interview with agency personnel, for three of eleven patients (Patient's #3,4 & 8) in the survey sample, the agency failed to ensure the supervision of nursing services. The findings include: 1. Patient #3 had a start of care date of 10/08/2021 with diagnoses that included a stage IV pressure ulceration of the sacral region, type II diabetes mellitus and paraplegia. The physician's orders for the certification period dated 06/05/2021 to 08/03/2021 included nursing services 2 times per week for 9 weeks for assessments and provide wound care. On 06/04/2021, for the recertification assessment Registered Nurse (RN) #2 documented Patient #3 had a stage IV pressure ulceration to the sacral region measuring 6.5 x 3.0 x 0.2 centimeters (cm), beefy red wound bed, moderate amount of drainage and no signs of infection. Interview and review of Licensed Practical Nurse #4's (LPN) notes dated 06/16/2021, 06/24/2021, 06/30/2021, 07/07/2021, 07/14/2021, 07/21/2021, 07/23/2021 and 07/28/2021 with the Supervisor of Clinical Services (SCS) on 08/03/2021 at 12:00 PM, identified LPN #4 documented Patient #3's stage IV pressure ulcer to the sacral region as a stage III pressure ulcer but failed to identify accurate staging of the wound in accordance to RN #2's assessments. 2. Patient #4 had a start of care date of 5/26/21 and diagnoses that included schizoaffective disorder, intellectual disabilities and epilepsy. The physician's orders dated 5/26/21 included nursing services 7 times a week for assessments, daily medication administration and pre-poring of evening medications. Physician orders directed to administer Enoxaprin Sodium (Lovenox) 150 milligrams/milliliter, inject 1 milliliter subcutaneous daily. Interview and review of LPN #1's nursing notes with the Supervisor of Clinical Services (SCS) on 8/04/21 at 11:30 AM identified on 7/25/21, 7/28/21, 7/29/21, 7/30/21 and 7/31/21, LPN #1 injected Lovenox in Patient #4's right deltoid (a three-headed muscle that caps the shoulder) and on 7/26/21, LPN #1 injected Lovenox in Patient #4's left deltoid and failed to ensure an RN supervised the LPN's performance in the provision of services and provision of treatments to ensure the Lovenox injection was administered subcutaneously versus intramuscularly and/or failed to alternate sites for injection. According to Drugs.com, Lovenox should not be administered by intramuscular injection., alternate injection sites between the left and right anterolateral and the left and right posterolateral abdominal wall. 3. Patient #8 had a start of care date of 10/27/20 and diagnoses that included a stage III pressure ulcer of the left heel, type II diabetes mellitus and chronic kidney disease, stage 3 and a placement of Foley catheter. The physician's orders dated 5/4/21 included nursing services three times a week for 8 weeks to provide wound care to the patient's stage III pressure ulcer to the left heel. The wound care orders directed to clean wound with normal saline, Aquacel Alginate, cover with 4x4 gauze, wrap with kerlix and secure with a tape by using aseptic technique. On 4/21/21, for the recertification assessment, RN#3 documented that the patient had a stage III pressure ulcer to the left heel measuring 4 x 3 x 0.2 centimeters (cm), pink wound bed, moderate amount of serosanguineous drainage and no odor. Interview and review of the LPN#4's notes dated 5/12/21, 5/14/21, 5/19/21, 5/21/21 and 5/26/21 with SCS on 8/04/21 at 12:45 PM identified that LPN#4 documented pressure ulcer to the left heel as stage IV but failed to identify accurate and/or consistent staging of the patient's left heel wound by LPN#4 that was consistent with RN#3's assessment of the wound.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on review of the clinical records and interview with agency personnel, for one of two patients (Patient #5) who received skilled services along with home health aide services, the agency professionals failed to provide on-site supervisory visits at a minimum every two weeks. The findings include: Patient #5 had a start of care date of 01/04/2021 and diagnoses that included psoriasis, chronic kidney disease and anemia. The physician's orders for the certification period of 05/04/2021 to 07/02/2021 included nursing services one time per week for nine weeks for vital signs monitoring and assessments, home health aide services twice per week for nine weeks to assist with personal care, physical therapy (PT) evaluation for home safety and a medical social worker (MSW) evaluation for accessing community resources. Interview and review of nursing notes from 05/04/2021 to 07/02/2021 with the Supervisor of Clinical Services (SCS) on 08/03/2021 at 11:45 AM, failed to identify home health supervisory visits no less frequently than every two weeks occurred. Review of the agency policy on Home Health Aide Plan of Care dated 01/18/2021, directed the clinician to conduct supervisory visits in the home at least every fourteen days to ensure the care was provided in accordance with the plan.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, for one of eleven patients (Patient #7) in the survey sample, the agency's Licensed Practical Nurse (LPN) failed to ensure clinical records were completed on the date service was rendered and incorporated into the patient's record within 7 days. The findings include: Patient # 7 had a start of care date of 7/01/2021 with diagnoses that included lymphedema, type II diabetes and asthma. The physician's orders included nursing services 2 times per week for 8 weeks for assessments, physical therapy (PT) services 1 time per week for 2 weeks then 2 times per week for 4 weeks, occupational therapy (OT) services 1 time per week for 1 week and home health aide services 7 times per week for 8 weeks for assistance with personal care. Interview and review of Patient #7's clinical notes with the Supervisor of Clinical Services (SCS) on 08/03/2021 at 12:22 PM, identified on 07/10/2021, 07/14/2021, 07/16/2021, 07/19/2021, 07/21/2021, 07/23/2021 and 07/28/2021, LPN #3 failed to ensure clinical records were completed on the date services were rendered and incorporated into the patient's record within 7 days. Review of the agency's policy for the Timeliness and Accuracy of Entries in the Clinical Record, identified clinicians must complete clinical progress notes on the date service was rendered. All clinical documentation completed by all disciplines must be incorporated into the patient's record within 7 days.