Every finding on record at Hunter Medical Services Inc

Purpose: Recertification survey Entrance Date: 4/25/2022 at 12:17 p.m. with the Alternate Administrator. Census: Licensed and Certified - 33 Patients Exit Date: 5/2/2022 at 3:30 p.m. with the Administrator, Alternate Administrator, Director of Nursing, and the Alternate Director of Nursing. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification survey Entrance Date: 4/25/2022 at 12:17 p.m. with the Alternate Administrator. Census: Licensed and Certified - 33 Patients Exit Date: 5/2/2022 at 3:30 p.m. with the Administrator, Alternate Administrator, Director of Nursing, and the Alternate Director of Nursing. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to send all necessary medical information in the discharge summary to the receiving health care practitioners in 2 (#6, #7) of 2 discharge records reviewed. The agency did not include the list of medications that the patients were taking at the time of discharge. The failure placed the patients at risk of adverse drug interactions, over-medication, and exacerbation of disease processes. Patient 6: Record review of Patient #6's clinical record revealed a Plan of Care that was dated 12/17/2021 to 2/14/2022. The Plan of Care listed Hypertension, Heart Failure, and Malignant Neoplasm of Unspecified of Bronchus or Lung as diagnoses. The Plan of Care listed the following medications: -Symbicort Inhalation- used to treat Asthma or Chronic Obstructive Pulmonary Disease -Phenazopyridine - used to treat pain, burning, increased urination and urge to urinate -Hydrocodone/Acetaminophen- used to treat pain -Furosemide- used to treat fluid retention and swelling -Fluconazole- used to treat and prevent fungal infections -Ferrous Sulfate- used to treat iron deficiency anemia -Famotidine- used to treat Ulcers and gastroesophageal reflux disease -Duloxetine- used to treat anxiety and depression -Bupropion- used to treat depression and smoking cessation -Atorvastatin- used to treat high cholesterol and triglyceride levels. -Calcium- dietary supplement -Aspirin- used to prevent heart attack or stroke The clinical record contained documentation of a Discharge Comprehensive Assessment dated 2/14/2022 written by Registered Nurse B. The documentation included a discharge summary. The discharge summary did not include the list of medications that Patient #6 was taking at the time of discharge. The clinical record contained a Medication Profile dated 2/14/2022. The Medication Profile listed the following medications: Bupropion- used to treat depression and smoking cessation Clonazepam- used to treat anxiety Hydrocodone/Acetaminophen- used to treat pain Levocetirizine Dihydrochloride- used to treat hay fever Metoprolol- used to treat high blood pressure, chest pain, and heart failure Nitroglycerin- used to treat chest pain Olopatadine Ophthalmic- used to treat itchy eyes Potassium Chloride- used to treat and prevent low blood potassium. Ropinirole- used to treat Parkinson's disease and restless legs syndrome Tiotropium Bromide Monohydrate Symbicort- used to treat Asthma or Chronic Obstructive Pulmonary Disease Albuterol Sulfate Inhaler- used to treat or prevent bronchospasm Alendronate Sodium- used to treat or prevent osteoporosis Docusate Sodium- used to soften stool Fluticasone- used to prevent asthma attacks Aspirin- used to prevent heart attack or stroke Atorvastatin- used to treat high cholesterol and triglyceride levels. Duloxetine- used to treat anxiety and depression Famotidine- used to treat Ulcers and gastroesophageal reflux disease Ferrous Sulfate- used to treat iron deficiency anemia Furosemide- used to treat fluid retention and swelling Phenazopyridine- used to treat pain, burning, increased urination and urge to urinate Patient #7: Record review of Patient #7's clinical record contained a Plan of Care dated 12/29/2021 to 2/26/2022. The Plan of Care listed Parkinson's Disease, Pneumonia (COVID), Hypertension, Major Depressive Disorder, and Hemiplegia as diagnoses. The Plan of Care listed the following medications: Tylenol- used to treat pain or fever Lisinopril- used to treat high blood pressure Propranolol- used to treat high blood pressure, chest pain, irregular heartbeat, and tremors Carbidopa-Levodopa-used to treat Parkinson's Disease The clinical record contained documentation of a Discharge Comprehensive Assessment dated 2/22/2022 written by Registered Nurse B. The documentation included a discharge summary. The discharge summary did not include the list of medications that Patient # 7 was taking at the time of discharge. The clinical record contained a Medication Profile dated 2/22/2022. The Medication Profile listed the following medications: Tylenol- used to treat pain or fever Lisinopril- used to treat high blood pressure Propranolol- used to treat high blood pressure, chest pain, irregular heartbeat, and tremors Carbidopa-Levodopa-used to treat Parkinson's Disease During an interview on 4/27/2022 at approximately 2:38 p.m. with the Alternate Supervising Nurse, the surveyor discussed the discharge summaries and asked questions. The Alternate Supervising Nurse informed the surveyor that the Discharge Summaries were sent to the physicians and that a list of medications was not included in the discharge summaries. The agency had a policy titled "Discharge Summary- Final Visit Note" labeled Reference #2060 with a revision date of 3/1/2011. The policy read in part: "Purpose - Provide current discharge/information and comply with state and federal requirements. Policy - There will be a Discharge Summary form for each patient discharged or transferred from the agency's services..."

Purpose of Visit: Complaint Investigation Entrance Date: 04/26/2021 An entrance conference was conducted with the agency office manager, Employee E at 11:55 a.m., as designated by the agency administrator, Employee A via telephone. L&CHH Census: 57 Complaint Investigation Intake numbers: TX2000236/233492; 220135;245994; 245960 Exit Date: 04/28/2021 An exit conference was conducted at 4:15 p.m. with the administrator, Employee A and Employee E. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. The agency was informed that if violations were cited, the agency would receive the Statement of violations within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Violations. Abbreviations: Licensed and Certified Home Health Services-L&CHHS Registered Nurse (RN) Physical Therapist (PT) Licensed Vocational Nurse (LVN) POC- Plan of Care SOC- Start of Care SN- Skilled Nursing VA-Veterans Administration hha-Home Health Aide

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 record review and interview the agency failed to ensure that all entries were legible, clear, complete, and appropriately authenticated and dated with a signature and a title (occupation) of a primary author who had reviewed and approved the entry, in five (Clients # 1, 2, 3, 4 and 5) of five records reviewed for authentication. The failure could place the clients at risk of harm if care and treatment was not reviewed, approved and authenticated by the primary author. FINDINGS INCLUDED: Clinical Record # 1: Client # 1's record included a POC for the treatment period of 03/15/2019 to 05/13/2019 with a SOC date of 01/14/2019. The POC was signed by RN R and dated 03/13/2019. The POC included a primary diagnosis of radiculopathy of lumbar region. The POC included an order for SN visits two times per 60 days and PT evaluation and treat. The record also included a PT evaluation signed by PT, Contractor P and dated 03/22/2019 that included an order for PT one time per week, evaluation only. A PT re-evaluation was also included in the record. The re-evaluation was signed by PT, contractor Q and dated 04/10/2019. The re-evaluation included an order for PT visits 1 time per week for one week and two times per week for one week beginning 04/10/2019. The record included a physician order for patient discharge that was dated 04/17/2019 and signed by supervising nurse, RN C. The POC dated 03/13/2019, the PT evaluation dated 03/22/2019, the PT re-evaluation dated 04/10/2019 and the order dated 04/17/2019 contained illegible physician signatures. The primary physician listed on the orders was Identifier Aa. During an interview on 04/28/2021 at 3:21 p.m., the surveyor asked for the attestation/signature log/authentication of the illegible signature. The attestation/signature log/authentication was not provided. The surveyor asked why the agency did not have the attestation/signature log/authentication of the illegible signature. The administrator, Employee A replied, "We were not aware of that." Clinical Record # 2: Client # 2's record included a POC for the treatment period of 03/11/2021 to 05/09/2021 with a SOC date of 11/11/2020. The POC was signed by RN F but did not include authentication of the RN title and was dated 03/10/2021. The POC included a primary diagnosis of hemiplegia following infarct affecting left non-dominate side. The POC included an order for SN visits one time per week for nine weeks. The record included physician orders dated 02/22/2021, signed by RN F but did not include authentication of the RN title. Clinical Record # 3 Client # 3's record included a POC for the treatment period of 12/25/2019 to 02/22/2020 with a SOC date of 09/02/2019. The POC was signed by supervising nurse RN C and was dated 12/25/2020. The POC included a primary diagnosis of quadriplegia, C5-C7 complete. The POC included an order for SN visits for six times per week for nine weeks and hha visits for seven times per week. The record also included a POC for treatment period 11/01/2019 to 12/24/2019. The POC was undated and not signed by an agency RN. The POC included an order for SN visits for seven times per week for nine weeks and hha visits for seven times per week. Clinical Record # 4: Client # 4's record included a POC for the treatment period of 04/04/2019 to 06/02/2019 with a SOC date of 04/05/2019. The POC was signed by RN S and dated 04/05/2019. The POC included a primary diagnosis of Schizophrenia. The POC included an order for SN for one time per week for one week and home hha visits for two times per week. The POC included an area to be signed and dated by Client # 4's physician. The POC dated 04/05/2019 was not signed by a physician. During an interview on 04/28/2021 at 3:25 p.m., the surveyor asked where the signed physician order/POC was located. The office manager, LVN E replied, "[Client # 4] was non-skilled." Clinical Record # 5: Client # 5's record included a POC for the treatment period of 12/20/2019 to 02/17/2020 with a SOC date of 12/20/2019. The POC was signed by RN T and dated 12/20/2019. The POC included a primary diagnosis of End Stage Renal Disease. The POC included an order for SN for one time per week for nine weeks and home hha visits for three times per week for six weeks. The POC dated 12/20/2019 was not signed by a physician. During an interview on 04/28/2021 at 3:40 p.m., the surveyor asked where the signed physician order/POC was located. The office manager, LVN E replied, "We just get an auth for VA clients." The surveyor requested the authorization. The authorization was by Identifier 5a, a VA payer source that required the agency to following Medicare guidelines, which would include a signed physician's order/POC. LVN E also replied, "[Client # 5] did have skilled services." Agency policy titled "TX.5 Physician Orders" dated 040418 read in part "Purpose ...To ensure patient care is provided in accordance with physician's orders and federal and state laws and regulations Policy A. Agency will obtain orders and provide care in accordance with physician's orders which are established prior to initiating patient care and reviewed/revised by physician every 60 days as ordered ...M. All orders are signed by the physician within ...60 calendar days of the date the order is given ...T. Illegible physician signatures will have a letter of attestation or signature log. U. Electronic signatures are acceptable. Authentication by the physician should be available if requested by the agency ..."