Every finding on record at Human Touch Home Health Care Agency Inc Grand Junction

A recertification survey was completed on 11/20/24. Four deficiencies were cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to have an emergency preparedness plan that included a facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings Include: 1. On 11/20/24 a review of the agency's emergency preparedness plan revealed the plan did not include a facility-based and community-based risk assessment, utilizing an all-hazards approach. a. The agency failed to have an emergency preparedness plan that included a facility-based and community based risk assessment. During an interview 11/20/24, at 12:20 p.m., The administrator stated the agency did not have documentation, nor a plan including a facility- based and community based risk assessment that utilizes an all-hazards approach.

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 interview and record review, the agency failed to maintain an emergency preparedness training and testing program based on a Centers for Medicare and Medicaid (CMS) standards based emergency preparedness plan, risk assessment, policies, procedures, and the communication plan, in accordance with Section 483.73(d). Findings include: 1.On 11/20/24 a review of the personnel files revealed no evidence to conclude personnel had been trained or demonstrated knowledge of CMS standards based emergency procedures within the regulated time frame. a. The agency failed to maintain emergency preparedness training to demonstrate staff knowledge of emergency procedures. During an interview on 11/20/24, at 12:20 p.m., the administrator stated the training program had not been maintained to train each staff member providing services within the past two years. They continued to state personnel did not complete ongoing training that trained and tested on a CMS standards based facility emergency preparedness plan, risk assessment, policies, procedures, and communication plan. They concluded by stating there was no documentation available regarding ongoing training and testing on a CMS standards based emergency preparedness plan, risk assessment, policies, procedures, and communication plan.

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 1 of 1 discharged patient, who required an OASIS to be transmitted, record reviewed (Patient #6); and based on interview and record review of CMS OASIS Error Detail report, the agency failed to electronically transmit current and accurate data regarding each beneficiary with respect to which information was required to be transmitted within 30 days of completing the assessment of the beneficiary for 3 current patients (Patients #1, #2 and #4) whose data was transmitted from 11/1/23 through 11/19/24. Findings include: A. The agency failed to ensure patients who had Medicare, including Medicare advantage plans and Medicaid insurance plans OASIS data was submitted to CMS. 1. The clinical record for Patient #6 was reviewed on 11/19/24. The plan of care (POC) for the certification period dated 2/14/24 to 4/13/24 revealed a start of care date of 10/17/23; diagnoses included COVID-19, unspecified fall, weakness and unsteadiness on feet. POC orders included physical therapy (PT) visits once a week for one week and twice a week for eight weeks for therapeutic activities, gait training and balance training; and occupational therapy (OT) visits once a week for one week and twice a week for nine weeks for activities of daily living (ADL) retraining. a. The agency failed to ensure Patient #6's OASIS was transmitted to CMS. On 11/19/24, a review of Patient #6's insurance information revealed the patient had a Medicare advantage plan. On 11/19/24, review of the Patient #6's record revealed the patient was discharged from services on 2/27/24. Further review of Patient #6's record failed to reveal an OASIS that was completed or transmitted to CMS. During an interview on 11/20/24 at 11:24 a.m., the administrator confirmed there was no discharge OASIS that was completed for Patient #6. The administrator also stated the agency had issues regarding clinicians creating and submitting discharge OASIS. B. The agency failed to ensure OASIS data was transmitted within 30 days of completing the assessment. 1. Review of the OASIS Error detail report from 11/1/24 through 11/19/24 revealed five assessments which pertained to 3 different patients, which were submitted more than 30 days after the "M0090" date which was the last date information used to complete the the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. 2. Review of the OASIS error report for 11/1/24 t 11/19/24 revealed Patient #4 had his OASIS submitted for the following assessments - an assessment was created on 10/19/23 and transmitted on 11/28/23 or 40 days after the M0090 date - an assessment was created on 12/18/23 and transmitted on 2/8/24 or 52 days after the M0090 date - an assessment was created on 4/15/24 and transmitted on 6/3/24 or 49 days after the M0090 date 3. Similar findings were found for Patients #1 and #2. 4. During an interview on 11/20/24 at 11:24 a.m., the administrator stated the agency had issues ensuring the OASIS reports were submitted in a timely manner. The administrator stated she had identified and was working on a plan to fix this issue.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge summary was sent to the primary care practitioner within five business days of discharge and a transfer summary sent within two business days of becoming aware of a patient's transfer for 1 of 2 discharged patients records reviewed (Patients #7). Findings include: 1. The clinical record for Patient #6 was reviewed on 11/18/24. The plan of care (POC) for the certification period dated 9/12/24 to 11/10/24 revealed a start of care date of 1/26/22; diagnoses down syndrome, congenital hypotonia, and specified developmental disorder of motor function. POC orders included skilled nursing (SN) visits once every 60 days for assessment and recertification; and certified nursing aide (CNA) visits twice a day for 60 for assistance with all activities of daily living (ADL). a. The agency failed to send Patient #7's discharge summary to the physician within five business days of the patient's discharge. Review of Patient #7's clinical record revealed the patient was discharged from the agency on 10/15/24. Further review of the clinical record failed to reveal the agency had completed a discharge summary. Further review also revealed no notification had been sent to the physician regarding the discharge of Patient #7 from the agency. During an interview on 11/20/24 at 11:24 a.m., the administrator stated a clinician had completed a skilled nursing note on 10/15/24 which was the discharge summary. The administrator also stated the note was poorly documented and it was not sent to the physician within the five business days. The administrator reviewed the clinical record for Patient #7 and confirmed no discharge summary was sent to the physician.

A survey, prompted by #CO10273, was completed on 12/11//23. One deficiency was cited.

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 interviews and record reviews, the agency failed to ensure the Registered Nurse (RN) or applicable rehabilitation skilled professional conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care (SOC) date, for 2 of 2 clinical records reviewed whose SOC was completed by a physical therapist (PT) (Patients #2 and #3). Findings include: 1. The clinical record for Patient #2 was reviewed on 12/8/23. The plan of care for the certification period dated 11/21/23 to 1/19/24 revealed a SOC date of 11/21/23; primary diagnoses included chronic kidney disease stage 3, unspecified abnormalities of gait and mobility, liver transplant status, other amnesia, iron deficiency anemia secondary to blood loss (chronic), and hyperthyroidism, unspecified. Plan of care orders included physical therapy (PT) two times weekly for eight weeks visits to maximize functional capacity and safe mobility. a) The agency failed to start services for Patient #2 on a Physician's SOC date. Record review revealed a physician's order for home health to conduct a SOC assessment for Patient #2 on 11/10/23 that was later extended one week to 11/17/23. Review of the SOC completed by PT #2 on 11/21/23 revealed the agency initiated services on 11/21/23. This was four days after the physician's ordered start of care of 11/17/23. Further record review failed to show PT #2 communicated with Patient #2's physician and received authorization to delay the initial comprehensive assessment. 2. The clinical record for Patient #3 was reviewed on 12/8/23. The plan of care for the certification period dated 10/31/23 to 12/29/23 revealed a SOC date of 10/31/23; primary diagnoses included sepsis, unspecified organism, hyperlipidemia, type 2 diabetes mellitus without complications, essential [primary] hypertension, transient cerebral ischemic attack, unspecified, multiple sclerosis, urinary tract infection, site not specified, weakness and difficulty in walking, not elsewhere classified. Plan of care orders included PT two times weekly for nine weeks visits to maximize functional capacity and safe mobility. a) The agency failed to start services for Patient #3 within 48 hours of referral. Review of the referral, received on 10/26/23, revealed Patient #3 was scheduled to discharge home on 10/27/23 from the hospital. Review of the SOC completed by PT #2 on 10/31/23 revealed the agency initiated services on 10/31/23. This was four days after the agency accepted the referral and the patient was discharged from the hospital. Further record review failed to show PT #2 communicated with Patient #3's physician and received authorization to delay the initial comprehensive assessment. 3. During an interview on 12/11/23 at 1:56 p.m., PT #2 stated the planned SOC date for Patient #2 was on 11/10/23, but per patient's spouse request, the SOC date was extended for one week to 11/17/23. When the agency was unable to meet a SOC date within 48 hours, PT# 2 stated he called the physician for an order to delay the SOC and this was documented in communication notes in the Electronic Medical Record (EMR). However, no documentation was found in EMR and PT#2 acknowledged that there was no communication documented prior to the SOC. During an interview on 12/11/23 at 2:23 p.m., Employee #3 stated that as the intake coordinator, he accepted referrals after confirming insurance information and availability of agency clinicians; He stated the individual cases were assigned to available staff to complete SOC assessments within the 48 hour requirement per regulation. Employee #3 stated when a SOC was delayed, he would contact the hospital case manager to inform a physician for a verbal order (VO), Employee #3 stated he had received an electronic mail from PT #2 to request a delayed SOC for Patient #2 per family request. He further stated he emailed the hospital case manager but acknowledged he did not follow up to ensure the physician authorization to delay the SOC had been received.. During an interview on 12/11/23 at 4:00 p.m., the administrator confirmed the physician's orders were not followed by the agency regarding the start of care time frames for Patients #2 and #3.

A recertification survey was completed on 1/5/22. Three deficiencies were cited.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure a comprehensive assessment that accurately reflected the patient's current health status had been updated and revised for 1 of 7 active patients reviewed (Patient #7). Findings include: AGENCY POLICY According to the agency's policy titled, "Ongoing Assessments," revised November 2017 (in pertinent parts): "During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter. Re-assessments should focus on: -Patient's response to care -Changes in patient condition -Changes in patient diagnoses -Changes in patient's care environment or support systems Based on each reassessment, the plan of care, including problems, needs, goals and outcomes will be reviewed and revised accordingly by the clinician." 1. During an interview on 1/3/22 at 10:55 a.m., the director of nursing (DON) stated comprehensive assessments were completed by the patient's case manager, which was the primary registered (RN) assigned to the patient or if the patient was not seen by nursing then the primary physical therapist assigned to care for the patient. During an interview on 1/4/22 at 2:54 p.m., the DON stated in the ideal world every box on the comprehensive assessment would be filled out. The DON stated that some of her employees were new and she was in the process of educating the new staff on how to complete comprehensive assessments. 2. The clinical record for Patient #7 was reviewed on 1/3/22. The Plan of Care for the certification periods dated 10/12/21 to 12/10/21 and 12/11/21 to 2/8/22, revealed a start of care date of 6/19/20; diagnoses include type 2 diabetes with foot ulcers, disorders of visual cortex, psychophysical visual disturbances, psychotic disorder with delusions due to known physiological condition, hypertension, and generalized anxiety disorder. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days for wound care; to observe diabetic status and presence of complications; monitor blood glucose as ordered and instruct the physician of blood glucose greater than 300 or less than 60; assess, instruct, administer, and monitor patient on medication administration; instruct patient on home safety measures, instruct patient to wear footwear when ambulating, and instruct patient on measures to detect and alleviate edema (swelling caused by excessive fluid trapped in a body's tissue) and home health aide (HHA) visits Monday through Saturday for a duration of one hour for assistance with bathing, dressing and hygiene. a) The agency failed to ensure Patient #7's comprehensive assessments were complete and had been updated and revised to accurately reflect the patient's current health status. Review of the recertification comprehensive assessment (pertaining to the certification period dated 10/12/21 to 12/10/21) completed on 10/7/21 by RN #7 revealed RN #7 failed to complete the following sections of the Outcome and Assessment Information Set (OASIS): allergies (section 18), patients contact with physician (section 19), management of oral medications (section 107), medication profile (section 112), and durable medical equipment (section 118). Review of the recertification comprehensive assessment (pertaining to the certification period dated 12/11/21 to 2/8/22) completed on 12/9/21 by RN #7 revealed RN #7 failed to complete the following sections of the OASIS: Emergency Preparedness Planning, patient contact with physician (section 19), if the patient had suffered from a urinary tract infection in past 14 days (section 69), cognitive functioning (section 83), when confused (section 84), when anxious (section 85), depression screening (section 86), cognitive, behavioral, and psychiatric symptoms (section 87), frequency of disruptive behavior symptoms (section 88), factors affecting learning (section 90), drug regimen review (section 104), medication follow-up (section 105), patient/caregiver drug education intervention (section 106), management of oral medications (section 107), failed to list the drug names, dosage, route, and frequency for patient #7's two intravenous (IV) medications (section 111), medication profile (section 112), safety measures (section 120), identify frequencies by care type and payer (section 121), description of service and explanation of specific intervention, assessments, teaching and treatments (section 122), goals, including measurable outcomes and information to demonstrate progress towards goals (section 123), discharge plans/rehab potential (section 124), and supervision visit. During an interview on 1/4/22 at 6:59 p.m., RN #7 stated that the incomplete sections on both recertification comprehensive assessments completed on 10/7/21 and 12/9/21 by her were an oversight on her part. RN #7 stated the agency's expectation was that all boxes on the OASIS be completed and she should have completed those sections. b) The agency failed to ensure Patient #7's comprehensive assessment had been updated and revised to accurately reflect the patient's current health status. Review of the recertification comprehensive assessment (pertaining to the certification period dated 10/12/21 to 12/10/21) completed on 10/7/21 by RN #7 showed that Patient #7 suffered from two diabetic ulcers: one on his left plantar (bottom) foot and one on his right big toe. Review of SN notes from 10/12/21 to 12/25/21, completed by RN #7 and RN #9, showed that Patient #7 was receiving wound care for two diabetic ulcers: one on his left plantar foot and one on his right big toe. Review of the recertification comprehensive assessment (pertaining to the certification period dated 12/11/21 to 2/8/22) completed on 12/9/21 by RN #7 failed to list Patient #7's right big toe diabetic ulcer. Further review showed RN #7 listed Patient #7 as having no skin problems identified in section 60 of the OASIS. During an interview on 1/4/21 at 6:59 p.m., RN #7 stated failing to list Patient #7's right big toe diabetic ulcer on the recertification assessment completed by her on 12/9/21 was an oversight by her. RN #7 confirmed Patient #7 had two diabetic ulcers and both should have been listed. Further, RN #7 stated she made a mistake when she listed Patient #7 as having no skin issues identified in section 60 of the OASIS.

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 provided only as ordered by the physician for 1 of 2 active patients reviewed who were receiving intravenous (IV) fluids (Patient #6). Findings include: AGENCY POLICY According to the agency policy titled, "Verification of Physician Orders" revised November 2017 (in pertinent parts): "Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients. An order or prescription will be verified when there is a question or discrepancy in the order/prescription and when the order is communicated by someone other than the physician or his/her agent." 1. The clinical record for Patient #6 was reviewed on 1/5/22. The Plans of Care for the certification periods dated 9/25/21 to 11/23/21 and 11/24/21 to 1/22/22 revealed a start of care date of 8/7/19; diagnoses included acute gastritis without bleeding, epigastric (upper abdominal) pain, nausea, cyclical vomiting, transient cerebral ischemic attack, and chronic pancreatitis. Plan of care orders included skilled nursing (SN) services two times a day for 60 days for IV medication administration, peripherally inserted central catheter (PICC) line care including weekly dressing changes, medication management and education, and physical therapy (PT) services two times a week for eight weeks for therapeutic exercise including instruction in a home exercise program, transfer training, gait training, neuromuscular electrical stimulation for muscle re-education, soft tissue mobilization, manual therapy, balance and safety training. a) The agency failed to ensure physician orders were followed for administration of IV fluids for Patient #6. Review of physician orders for the certification period of 11/24/21 to 1/22/22 revealed an order written by Physician #10, dated 11/29/21, instructing the home health SN to draw complete blood count (CBC) with differential (a blood test that measures the number of red blood cells, white blood cells, and platelets in the blood, including the different types of white blood cells) and a basic metabolic panel (BMP) (a blood test that measures eight different substances in your blood) once a week and to administer one liter (L) of normal saline and Zofran 4mg IV 1-2 times per week at home. Review of a physician order dated 12/6/21 written by RN #8 and signed by Physician #11 on 12/13/21, stated " frequency and duration update; effective 12/6/21: SN to draw CBC with diff and BMP weekly and SN to administer 1L normal saline 1-2x weekly per written order by [Physician #10], at Rocky Mountain Cancer Center." Review of Patient #6's clinical record failed to show evidence of any other physician orders. Review of SN a.m. and p.m. notes from 11/29/21 to 12/25/21, completed by RN #8, failed to show evidence of administration of normal saline fluid via an IV to Patient #6. During an interview on 1/5/22 at 11:54 a.m., the DON stated RN #8 should have documented administration of IV fluids in the IV section of the SN notes. The DON reviewed SN notes from 12/6/21 to 12/12/21 and acknowledged there was no evidence of RN #8 administering one liter of normal saline to Patient #6 during this time period. During an interview on 1/5/22 at 12:22 p.m., RN #8 stated the order written on 11/29/21 was incorrect. RN #8 stated the fluids she received from the pharmacy for IV hydration of Patient #6 was Lactated Ringers Solution (a prescription medicine used as a source of electrolytes, calories and water for hydration) not normal saline. RN #8 also stated the order should have been written for pro re nata (PRN- as needed) frequency instead of one to two times a week. RN #8 stated she had not administered normal saline or Lactated Ringers Solution via IV to Patient #6 since 11/29/21 as Patient #6 had not needed the hydration via IV fluids. RN #8 acknowledged she should have communicated with Physician #10 and/or #11 to clarify the order for IV hydration.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure clinical records contained accurate documentation of pertinent past and current findings in accordance with accepted professional standards for 5 of 10 patients' records reviewed (Patient #2, #4, #6, #7 and #8). 2. The clinical record for Patient #2 was reviewed on 1/4/22. The plan of care for the certification periods dated 12/10/21 to 2/7/22 revealed a start of care date of 12/10/21; diagnosis of type 2 diabetes mellitus with hyperglycemia. Plan of care orders included skilled nurse (SN) visits three times a day for 60 days for blood sugar monitoring, insulin administration, assessment and observation related to blood pressure fluctuations. a)The agency failed to ensure the RN documented each visit or a change in each visit. Review of the SN notes from 12/10/21 to 1/4/22 revealed RN # 7 failed to document Patient #2's SN visit 10 times (12/24/21x3, 12/25/21x3, 12/6/21x3 and 12/28/21x1). During an interview on 1/4/22 at 2:50 p.m., the administrator stated that the patient's family had administered insulin on those days and RN #7 had not documented the reason for the missed visits including how Patient #2 received insulin. The administrator further stated that RN #7 had been having issues with her device syncing notes. During an interview on 1/4/22 at 8:00 p.m., RN #7 stated Patient #2's family was in town and completed the administration of insulin. RN #7 further stated she had connection issues and could not log in to note this or that RN #7 saw Patient #2 on on 12/28/21. 3. The clinical record for Patient #4 was reviewed on 1/3/22. The plan of care for the certification periods dated 9/20/21 to 11/21/21 and 11/22/21 to 1/20/22 revealed a start of care date of 5/26/21; diagnosis of osteomyelitis of vertebra, sacral and sacrococcygeal region and pressure ulcer of sacral region, stage 4. Plan of care orders included SN visits once every other week for observed wound management, supra pubic management and colostomy management. Wound care as follows to left lateral hip pressure wound and coccyx/sacral pressure wound daily and as needed (PRN). a) The agency failed to ensure the RN documented wound care on the accurate hip as required per physician orders at each visit. Review of the SN notes on 6/2/21 revealed the RN #4 documented wound care on the right lateral hip. During an interview on 1/4/22 at 2:45 p.m., the administrator stated the RN #4 should know better and was probably rushing to document. Similar findings were revealed in the clinical records of Patients #6 and #8. Findings include: 1. The clinical record for Patient #7 was reviewed on 1/3/22. The Plan of Care for the certification periods dated 10/12/21 to 12/10/21 and 12/11/21 to 2/8/22, revealed a start of care date of 6/19/20; diagnoses include type 2 diabetes with foot ulcers, disorders of visual cortex , psychophysical visual disturbances, psychotic disorder with delusions due to known physiological condition, hypertension, and generalized anxiety disorder. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days for wound care; to observe diabetic status and presence of complications; monitor blood glucose as ordered and instruct the physician of blood glucose greater than 300 or less than 60; assess, instruct, administer, and monitor patient on medication administration; instruct patient on home safety measures, instruct patient to wear footwear when ambulating, and instruct patient on measures to detect and alleviate edema (swelling caused by excessive fluid trapped in a body's tissue), and home health aide (HHA) visits Monday through Saturday for a duration of one hour for assistance with bathing, dressing and hygiene. a) Clinical record review revealed the agency failed to ensure the LPN documented blood glucose levels as required per physician orders at each visit. Review of a plan of care completed by RN #7 on 10/12/21 for certification period 10/12/21 to 12/10/21 and signed by Physician #12 on 10/21/21 and of a plan of care completed by RN #7 12/11/21 for certification period 12/11/21 to 2/8/22 and signed by Physician #12 on 12/17/21, included orders for SN to perform blood glucose checks at each SN visit and pro re nata (PRN). Review of a.m. SN notes from 10/12/21 to 12/25/21 revealed LPN #9 failed to document Patient #7's blood glucose level 9 times (10/22/21, 12/1/21, 12/2/21, 12/3/21, 12/4/21, 12/5/21, 12/7/21, 12/8/21 and 12/12/21). During an interview on 1/4/22 at 12:50 p.m., LPN #9 stated she checks Patient #7's blood glucose as ordered at each visit. LPN #9 stated if the blood glucose levels were not in her note she probably forgot to document it. LPN #9 stated she sustained a concussion from a car accident in November of 2021 and after the accident and she was more forgetful. b) Clinical record review revealed the agency failed to ensure RN #7 documented all visits she provided to Patient #7. Review of SN notes from 10/12/21 to 12/25/21 revealed no documentation for scheduled SN visits for the following 4 visits: the a.m. and p.m. visit for 11/14/21, the p.m. visit for 12/5/21 and the p.m. visit for 12/8/21. During an interview on 1/5/22 at 11:54 a.m., the DON stated that RN #7 was scheduled to see Patient #7 for both the a.m. and p.m. visit on 11/14/21 and for the p.m. visit on 12/5/21 and 12/8/21. During an interview on 1/4/22 at 6:59 p.m., RN #7 stated she had never missed or cancelled a visit with Patient #7. RN #7 stated sometimes the agency's electronic medical record system had problems with notes getting stuck in the server and not showing up in the system. RN #7 stated perhaps this was what occurred with her documentation for these visits. c) Clinical record review revealed the agency failed to ensure the HHA documented care as provided to Patient #7. Review of the HHA care plan dated 10/12/21 and completed by RN #7 assigned the HHA to complete the following tasks at each visit: remind patient to take/assist patient with taking medication, showers, shampoo hair, perform perineal (cleaning the private areas of a patient) care, apply lotion, perform incontinence care (cleaning urine or stool off of a patient), assist patient to select clothing, dress, brush/comb hair, assist patient to walk with a cane, encourage/prepare fluids, clean bathroom and change linens. The HHA also was assigned to assist Patient #7 with shaving per his request. Review of HHA notes for Patient #7 for the Monday through Saturday once a day visit from 10/12/21 to 12/31/21 (a total of 67 visits) revealed HHA #13 failed to document the following tasks: -medication reminders 67 times -perineal care 67 times -incontinence care 67 times -assist patient to walk with a cane 67 times, -encouraging/preparing fluids 67 times, -cleaning the bathroom 67 times, -changing the linens 67 times, -shampoo hair seven times, and -apply lotion two times. HHA #13 documented the following tasks not assigned to Patient #7: -clean the work areas 46 times; -emptying the trash three times; - clean dentures and brush mouth with toothettes one time. During an interview on 1/4/22 at 12:39 p.m., HHA #13 stated she provided care for Patient #7 Monday through Saturday and assisted him with dressing, showering, keeping his house clean, and helping him prepare food. HHA #13 stated the agency provided a HHA care plan and those were the tasks she was to assist Patient #7 with at each visit. HHA #13 stated that Patient #7 refused tasks at times. HHA #7 she has worked with Patient #7 for a long time and when Patient #7 would refuse a task, she would document that he refused a task on her daily note as this is the agency's expectation. HHA #13 further stated she recently stopped documenting when Patient #7 refused a task if the refusal was a pattern for Patient #7. HHA #13 stated when she assisted Patient #7 with his daily shower if she noted Patient #7 had been incontinent of urine or stool she assisted him with cleaning the urine and/or stool off his body. Additionally, if HHA #13 noted urine or stool on the floor or linens she would clean the soiled area and/or the linens. During an interview on 1/4/22 at 6:59 p.m., RN #7 stated she was the RN who provided supervisory visits for HHA #13. RN #7 stated she was not aware that HHA #13 had failed to document completion of several tasks assigned to her for Patient #7 from October to December 2021 including perineal care, incontinence care, bathroom cleaning and linen changes. RN #7 stated she often treated Patient #7 in the evenings after HHA #13 visits had occurred and she observed these tasks had been completed with Patient #7. RN #7 stated perhaps HHA #13 did not understand what the terms perineal and incontinence care meant and that was why she had not documented completion of those tasks. RN #7 also stated that when HHA #13 stated she cleaned the work area for Patient #7, HHA #13 was probably referring to cleaning the bathroom or area she assisted Patient #7 with hygiene/dressing after she assisted Patient #7 as RN #7 observed these areas to be clean at her visits. The surveyor attempted to re-interview HHA #13 on 1/5/22 at 8:48 a.m. but HHA #13 did return the surveyors' call. During an interview on 1/5/22 at 11:54 a.m., the DON stated that she had educated HHA #13 approximately 6 months ago on the importance of accurate documentation and HHA #13 was doing better with her documentation. The DON stated she has not recently checked HHA #13 documentation with Patient #7. The DON stated she felt HHA #13 was providing the care assigned to her for Patient #7, but was not documenting the care accurately. The DON stated she felt HHA #13 might not understand that incontinence and perineal care was the boxes she should check when HHA #13 assisted Patient #7 to remove urine or stool from his body. The DON also stated that she felt HHA #13 was marking cleaning the work area to indicate cleaning the area that she had assisted Patient #7 with hygiene and dressing. d) Clinical record review revealed the agency failed to ensure orders for vital signs were consistent on physician orders and plans of care for Patient #7. Review of a plan of care completed by RN #7 on 10/12/21 for certification period 10/12/21 to 12/10/21, and signed by Physician #12 on 10/21/21, and of a plan of care completed by RN #7 on 12/11/21 for certification period 12/11/21 to 2/8/22 ,and signed by Physician #12 on 12/17/21, included orders for SN to assess vital signs at each SN visit. Review of physician orders completed by RN #7 for Patient #7 on 10/12/21, and signed by Physician #12 on 10/21/21, and completed by RN #7 on 12/11/21, and signed by Physician #12 on 12/17/21, stated vital signs to be assessed weekly due to patient's refusal and paranoia. Review of a.m. and p.m. SN notes from 10/12/21 to 12/25/21 revealed Patient #7's vitals were documented 22 times the following days: 10/19/21 during the p.m. shift; 10/26/21 during the p.m. shift , 11/2/21 during the p.m. shift, 11/15/21 during the a.m. and p.m. shift; 11/16/21 during the p.m. shift, 11/17/21 during the p.m. shift, 11/18/21 during the a.m. and p.m. shift, 11/21/21 during the a.m. shift; 11/25/21 during the p.m. shift, 11/26/21 during the a.m. shift, 11/27/21 during the a.m. shift, 11/29/21 during the a.m. shift, 12/10/21 during the a.m. shift, 12/13/21 during the p.m. shift, 12/14/21 during the p.m. shift, 12/15/21 during the p.m. shift, 12/17/21 during the p.m. shift, 12/19/21 during the p.m. shift and 12/23/21 during the p.m. shift. Documentation indicates Patient #7's vitals were taken at least once a week for all weeks reviewed except for the week of 11/7/21 to 11/13/21. During an interview on 1/4/22 at 6:59 p.m., RN #7 stated the orders for assessing Patient #7's vitals were to take his vitals weekly. RN #7 stated typically they take a patient's vitals at each shift, but due to Patient #7's paranoia and refusal she had the frequency changed to once a week. RN #7 stated sometimes due to Covid she checked Patient #7's vitals more frequently than once a week if he would allow her to, but at a minimum she took them once a week. Upon reviewing the plans of care for the certification periods 10/12/21 to 12/10/21 and 12/11/21 to 2/8/22 RN #7 acknowledged the orders for assessing Patient #7's vitals on the plans of care did not match the physician orders. During an interview on 1/5/22 at 11:54 a.m., the DON stated that the standard order for vital assessment for agency patient's is for the SN to assess vitals at each SN visit. The DON stated that the plans of care for Patient #7 should have been updated to state assess vitals weekly due to his refusals and paranoia.