Every finding on record at Icare Home Health Agency LLC

A complaint survey, prompted by #CO110987, was completed on 12/18/24. One deficiency was 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 interviews and record review the agency failed to complete an updated and revised comprehensive assessment as the patients condition warranted for an improvement in health status in 1 of 1 discharged patients reviewed who received skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) services (Patient #3). Findings Include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Patient Assessments / Plan Of Care, (read in pertinent parts): "Written policies and procedures are established that describe the process for assessment, and the development of the plan of care. Agency staff provides efficient, and effective, case management, according to home health care agency policies and procedures. P&P describe, at a minimum -A comprehensive assessment is completed in a timely manner, consistent with the patient's immediate needs." 1. The clinical record for Patient #3 was reviewed on 12/17/24. The plan of care for the period dated 09/30/24 to 11/28/24, revealed a start of care date of 9/30/24; diagnosis included disorder of the skin and subcutaneous tissue, unspecified and Non-pressure chronic ulcer of other part of left foot with unspecified severity. Plan of care orders included SN visits once a week for 17 weeks for wound care. Further review of the plan of care revealed Registered Nurse (RN) Case Manager #3 documented under the system's assessment for skin “stasis ulcer to left foot.” Documented goals included patient wound status on the left foot will exhibit objective signs of healing without complication within the certification period. a. The agency failed to ensure an updated and revised comprehensive assessment was completed as warranted due to an improvement in Patient #3’s health status. Specifically, the RN Case Manager failed to perform a comprehensive assessment to address the change in condition presented by Licensed Practical Nurse (LPN) #4 on 10/1/24 until 10/30/24. Review of the start of care comprehensive assessment revealed on 9/30/24, RN Case Manager #3 documented Patient #3 had a wound present, specifically one observable stasis ulcer that was not healing. Record Review revealed LPN #4’s visit note dated 10/1/24 included assessment notes in which they documented the patient reported having a wound of her left foot however upon inspection they did not observe any wounds. Record review revealed care coordination documentation dated 10/1/24 at 3:10 p.m., in which LPN #4 brought attention to the care team including RN Case Manager #3 questioning what SN services were needed for Patient #3. Response given by RN Case Manager #3 on 10/1/24 at 3:14 p.m., stated “Her wound care. We are treating a patient with major health issues. Once you go see her, you will figure it out.” Record review revealed on 10/1/24 RN Case Manager #3 received verbal orders for an alternate dressing while waiting for the ordered dressing. Record review revealed LPN notes dated between 10/1/24 to 10/30/24 included documentation which stated the skin assessment was performed and no observable wounds were present. Record Review revealed on 10/30/24, RN Case Manager #3 completed a comprehensive assessment. Documentation stated under skin assessment the skin was within normal limits and a new wound had not developed. Further review revealed under assessment notes, RN #3 documented “Wound care to right foot closed. Dry dressing placed." 2. During an interview on 12/18/24 at 10:53 a.m., the administrator stated if the LPN noticed a change in a patient's condition the RN was to re-evaluate the patient as soon as possible when questioned about the assessment process for a patient's change in condition. During an interview on 12/18/24 at 11:18 a.m., RN Case Manager #3 stated there was a wound present at the time of the start of care Oasis assessment and wound care was indicated based on the wound care orders and the start of care assessment. RN Case Manager #3 was unable to recall the exact date she was made aware by the LPN there was no wound present. The administrator confirmed LPN #4 documented 10/1/24 no wound was present on her assessment. RN Case Manager #3 was not able to recall the date she completed the comprehensive re-assessment; however recalled documentation of wound care was completed during the visit. The administrator confirmed 10/30/24 RN Case Manager #3 completed the comprehensive assessment and documented the wound was healed. During an interview on 12/18/24 at 1:20 p.m., the administrator stated that she was looking into the situation regarding the assessment for RN #3 and inquiring about “why it was done so late” and continued to state it would be discussed at the upcoming Quality Assurance and Performance Improvement meeting.

A recertification survey was completed on 5/2/24. Eight deficiencies were cited.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide emergency preparedness training to staff at least annually. Findings include: AGENCY POLICY According to an agency policy dated 2019 and titled, "Emergency Preparedness Training and Testing." "-Initial training in emergency preparedness policies and procedures, to all new and existing Agency staff, volunteers, and individuals providing services under arrangement, consistent with their expected roles. -Demonstrate staff knowledge of emergency procedures. -Provide emergency preparedness training at least annually. -Maintain documentation of all emergency preparedness training." 1. Review of the emergency preparedness meeting minutes dated 1/3/23 showed the administrator and director of nursing (DON) attended the agency's annual emergency preparedness training. Review of Employee #5's, date of hire 1/17/22, and Employee #9's, date of hire 12/26/22, personnel records failed to show documentation of annual emergency preparedness training. The meeting minutes failed to show other staff members were present at the agency's 2023 emergency preparedness training. Review of the emergency preparedness meeting minutes dated 1/3/24 showed the administrator and the vice president of the agency attended the agency's annual emergency preparedness training. The meeting minutes failed to show other staff members were present at the agency's 2024 emergency preparedness training. During an interview on 4/30/24 at 2:50 p.m., Employee #9 stated the only emergency preparedness training she received from the agency was upon hire. During an interview on 4/30/24 at 11:00 a.m., the administrator and DON stated employees receive emergency preparedness training at hire, but not annually as regulation required. During an interview on 5/2/24 at 2:41 p.m., the administrator stated she was unaware all staff were to receive emergency preparedness training annually. The administrator stated she would work to correct this deficiency by incorporating training for staff on issues identified in the agency's risk assessment for emergencies.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to conduct exercises to test the emergency plan annually for emergent issues which would potentially impact patient's of the agency. Specifically, the facility failed to conduct a full-scale exercise that was community based annually and conduct an additional exercise annually. Findings include: AGENCY POLICY According to an agency policy dated 2019 and titled, Emergency Preparedness Training and Testing, (read in pertinent parts): "The Agency must develop, and maintain, an emergency preparedness training and testing, program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and testing program must be reviewed, and updated, at least every two years. Agency must participate in a full-scale exercise that is community-based or, when a community-base exercise is not accessible, conduct an individual, facility-based functional exercise every two years; or if the Agency experiences an actual natural, or man-made, emergency that requires activation of the emergency plan, the Agency is exempt from engaging in its next required full-scale community-based, or individual, facility-based, every two years, following the onset of the actual event. Conduct an additional exercise every two years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following: -A second full-scale exercise that is community-based or individual facility based functional exercise; or -A mock disaster drill; or -A tabletop exercise or workshop that is lead by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions, designed to challenge an emergency plan Analyze the Agency's response to, and maintain documentation of, of all drills, tabletop exercises, and emergency events, and revise the Agency's emergency plan as needed." 1. Review of the agency's emergency preparedness documentation showed the agency's policies and procedures for emergency preparedness, along with the agency annual safety meetings. Further review of the annual safety meetings for 2021, 2022, 2023 and 2024 showed two office staff members were present for the meeting. At each meeting, the safety committee completed the following: reviewed the agency's safety manual, including waste disposal and hazardous medical device reporting; reviewed exits for the office building where the agency office was located; reviewed the location of the fire extinguishers located in the office and ensured the fire extinguishers were working and not expired; checked the agency supplies and disposed of all expired supplies; ensured the agency had personal protective equipment supplies; tested the agency's telephone tree which the agency would use in an emergency; and conducted a fire drill for office staff. There was no documentation to show the agency had conducted a community-based full scale exercise or facility-based full scale exercise, if a community-based exercise was not available, or a second exercise (either another community-based/facility-base exercise or a tabletop exercise) each year that pertained to emergent issues the agency patient's might experience as required by regulation. During an interview on 4/30/24 at approximately 11:00 a.m., the administrator stated the agency had conducted a risk assessment for the agency each year and had determined the top three emergency risks their patients might face included: an emergency related to a winter storm, an emergency related to hail, or an emergency related to Covid-19. The administrator acknowledged the emergency preparedness testing the agency had completed in 2021, 2022, 2023, and 2024 had been to conduct a fire drill with office members present on the day of the testing. The administrator acknowledged, the annual fire drills conducted with office staff was not a valid test to ensure the emergency procedures the agency had put in place would be effective for the three main identified risks the agency patient's might encounter. During an interview on 5/2/24 at 2:41 p.m., the administrator stated the reason the agency continued to do fire drills each year as their exercise to test their emergency preparedness procedures was a fire drill was the exercise the administrator was familiar with executing. The administrator again acknowledged a fire drill conducted with office staff did not meet the regulation, as the agency was not testing the agency's emergency preparedness procedures to ensure their procedures would be effective in assisting the agency to help their patients with emergencies the patient might encounter. The administrator stated she planned to discuss ways her agency could meet this regulation with the consultant she took her annual administrator training from to assist the agency with being compliant with this regulation.

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 interview and record review of the Centers for Medicare and Medicaid Services (CMS) Outcome and Assessment Information Set (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 45 patients who received an assessment from 4/1/23 through 4/30/24. Findings include: 1. Review of the OASIS Error detail report from 4/1/23 through 4/31/24 revealed 66 assessments, which pertained to 45 different patients, were submitted more than 30 days after the "M0090" date, which was the last date information used to complete the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. Review of the OASIS validation report for 4/1/23 through 4/31/24 revealed Patient A had her OASIS submitted on 1/30/24, for an assessment that had been completed on 11/30/23, approximately 62 days after the completion of the assessment. Review of the OASIS validation report for 4/1/23 through 4/31/24 revealed Patient B had his OASIS submitted on 2/24/24, for an assessment that had been completed on 12/28/23, approximately 59 days after the completion of the assessment. Review of the OASIS validation report for 4/1/23 through 4/31/24 revealed Patient C had her OASIS assessment submitted on 1/30/24, for an assessment that had been completed on 12/12/23, 49 days after the completion of the assessment. Similar findings of the agency failing to submit accurate OASIS assessments within the 30 day timeframe required by regulation was found for assessments submitted for the other 42 patients reviewed on the agency's OASIS validation report from 4/1/23 to 4/30/24. 2. During an interview on 5/2/24 at 1:05 p.m., the administrator acknowledged the agency was late sending OASIS reports. The administrator stated one of the issues in 2023 was the agency had an OASIS coordinator who was responsible for transmitting OASIS data. The administrator stated she terminated the OASIS coordinator when she realized the OASIS coordinator was transmitting many OASIS assessments late. Additionally, the administrator stated the current issue the agency faced, which resulted in late transmission of OASIS assessments, was the tardiness of clinicians in completing their comprehensive assessments and plans of care. The administrator stated if the clinician failed to complete their comprehensive assessments and plans of care in a timely manner, she was unable to transmit the OASIS with accurate information within the 30 day window required by regulation. The administrator stated she continued to educate her clinicians on the importance of completing and documenting their assessments accurately and timely to try to reduce this issue.

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 1 of 8 active patients reviewed who received physical therapy (PT) (Patient #7). Findings include: According to an agency policy, dated 2019, and titled, Initial Assessment Requirements, (read in pertinent parts): "All patients, referred for services, have an initial assessment. The initial assessment is conducted within 48 hours of referral, and/or within 48 hours of the patient's return home, or on the physician's ordered start of care date." 1. The clinical record for Patient #7 was reviewed on 4/29/24. The plan of care for the certification period dated 1/7/24 to 3/6/24 revealed a start of care date of 1/7/24; diagnoses included obstructive sleep apnea, congestive heart failure, chronic obstructive pulmonary disease, unsteadiness on feet, age-related physical debility, hypertension and dependence on other enabling machines and devices. Plan of care orders included PT visits two times a week for six weeks, three times a week for two weeks and two times a week for three weeks for therapeutic exercises, fall safety, gait training, home safety, and dynamic balance training starting 1/7/24; and speech therapy (ST) visits one time a week for one week starting 1/17/24 (no further information was provided). a) The agency failed to complete a comprehensive assessment within 48 hours of receipt of the referral for Patient #7. Specifically, the agency completed the assessment 18 days after receipt of the referral and failed to obtain a delayed start of care order until 16 days after the receipt of the referral for Patient #7. Review of referral documentation showed on 12/21/23 at 9:42 a.m., the agency received a fax from Patient #7's primary care physician (PCP) ordering PT for Patient #7 due to Patient #7 feeling weak after stopping therapy. Review of the clinical record showed PT #12 completed a start of care visit with Patient #7 on 1/7/24, 18 days after the agency received the referral order from Patient #7's PCP. Review of Patient #7's journal notes from 12/26/23 through 4/28/24 showed on 12/27/23 at 2:15 p.m., Scheduler #13 documented he spoke to Patient #7 and she had an appointment on Friday. Scheduler #13 documented he was unable to speak further with Patient #7 as she hung up the phone. Review Patient #7's record showed text messages between agency employees from 12/21/23 through 1/26/24. On 12/25/23 at 9:03 a.m., Scheduler #13 documented he tried to call Patient #7 for pre-admission information and had to leave a voice message as Patient #7 did not answer her phone. Scheduler #13 also documented he texted Patient #7. On 12/25/23 at 3:37 p.m., Scheduler #13 documented Patient #7 requested the agency call her on 12/26/23 to discuss pre-admission questions as she did not want to answer any questions on Christmas Day. On 1/2/24 at 8:16 a.m., Scheduler #13 documented he called Patient #7 to see if she was available at 10 a.m., but he had to leave a voice message and he also left a text message for Patient #7. On 1/2/24 at 8:26 a.m., Scheduler #13 documented Patient #7 requested a visit at 12:00 p.m. or later. On 1/2/24 at 3:07 p.m., Scheduler #13 documented Patient #7 was informed the agency did not have a therapist to complete a visit at 12:00 p.m. or later in the afternoon on 1/2/24, and Patient #7 stated she was available anytime the week of 12/31/23 through 1/6/24. On 1/2/24 at 4:26 p.m., Intake Coordinator #14 documented Patient #7 agreed to a visit from an agency PT on 1/3/24 at 10:45 a.m. On 1/3/24 at 11:05 a.m., PT #12 documented she arrived at Patient #7's apartment to complete the initial visit and Patient #7 was not home. On 1/7/24 at 9:28 a.m., PT #12 documented she was scheduled to see Patient #7 at 1:30 p.m. Review of supplemental orders for Patient #7, showed on 1/5/24 PT #12 spoke with Patient #7's PCP office and a verbal order was approved for a delayed start of care. Patient #7's PCP signed this verbal order on 2/5/24. This order was obtained 15 days after the agency received the referral order and Patient #7's record failed to show documentation of any other delayed start of care orders for Patient #7. During an interview on 5/1/24 at 10:44 a.m., PT #12 stated she suffered a head injury in January 2024 and did not recall seeing a patient in January 2024. Upon further interview, PT #12 stated she did remember completing a start of care visit for Patient #7. PT #12 stated when she received orders for a start of care, she would attempt to complete this visit within 24 to 48 hours after the referral was sent to the agency. PT #12 stated she remembered Patient #7 had several scheduling issues. PT #12 stated she thought some of the scheduling issues revolved around issues with insurance approval or receiving information back from Patient #7's PCP. PT #12 stated she went to see Patient #7 to complete the start of care visit (Wednesday 1/3/24), but Patient #7 was not home. PT #12 stated she only worked on weekends, so another PT attempted to complete the start of care visit with Patient #7, but was unsuccessful. PT #12 stated Case Managers #11 or #15 were typically responsible for calling a patient's PCP to obtain delayed start of care orders. During an interview on 5/2/24 at 11:37 a.m., Case Manager #11 reviewed Patient #7's record and confirmed the only delayed start of care order the agency received for Patient #7 was obtained on 1/5/24, 15 days after the agency received the order. Case Manager #11 stated the agency should have communicated to Patient #7's PCP about the delay and attempted to receive a delayed start of care order by 12/23/23. Case Manager #11 stated the agency needed to improve their process to obtain and document orders. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure an accurate comprehensive assessment was completed in 1 of 3 patients reviewed who had their comprehensive assessments completed by a therapist (Patient #3). Findings include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Comprehensive Assessment Requirements, (read in pertinent parts): "Each patient must receive, and an Agency must provide, a patient-specific, comprehensive assessment. A registered nurse must complete the comprehensive assessment, unless physical therapy, speech-language pathology, or occupational therapy is the only service ordered, by the physician. The comprehensive assessment must address, at least the following items: -The physical health component: -Diagnosis -Identification of additional health problems, or pertinent health history -Review of medications -Special nutritional needs, or dietary requirements, and weight loss -Other needed information that could impact the level of services required to meet the patient , and family, needs." 1. The clinical record for Patient #3 was reviewed on 4/29/24. The plan of care for the certification period dated 1/19/24 to 3/18/24, revealed a start of care date of 1/19/24; diagnoses included hypothyroidism, hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, malaise and history of falling. Plan of care orders included physical therapy (PT) visits one time a week for one week, two times a week for three weeks and one time a week for four weeks starting on 1/19/24 for strengthening, transfer training, gait training, endurance training, and fall risk assessment and education; occupational therapy (OT) visits one time a week for one week starting 1/21/24 for evaluation and treatment. Review of the plan of care for the certification period dated 3/19/24 to 5/19/24, revealed a start of care date of 1/19/24; diagnoses included: hypothyroidism, hypertension, type 2 diabetes mellitus, stage 4 chronic kidney disease, acute respiratory failure with hypoxia, acute embolism and thrombosis of bilateral lower extremities, pulmonary embolism with acute cor pulmonale, polyneuropathy, malaise, hyperlipidemia, difficulty walking, gastro-esophageal reflux disease, gout and cognitive communication deficit. Plan of care orders included PT visits one time a week for nine weeks starting 3/19/24 for gait training, endurance training and fall risk management; and OT to evaluate and treat. a) The agency failed to ensure on 1/19/24, an accurate start of care comprehensive assessment was completed for Patient #3. Specifically, the director of rehab (DOR) failed to list all of Patient #3's diagnosis appropriate to this episode of care and failed to accurately assess Patient #3's endocrine system. Review of the start of care comprehensive assessment revealed, on 1/19/24, the DOR inaccurately completed the diagnosis section of the assessment. Specifically, the DOR documented Patient #3's primary diagnosis for the initiation of this home care episode was hypothyroidism and other diagnoses included hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, and other malaise. The DOR failed to document the diagnosis found on Patient #3's referral documentation. Review of referral documentation sent to the agency on 1/17/24, by Patient #3's primary care physician's (PCP) office, showed Patient #3 had a PCP visit completed on 1/16/24 and had the following diagnoses listed: Stage 4 chronic kidney disease, gout, hypertension, and type 2 diabetes mellitus. The 1/17/24 referral paperwork showed Patient #3 was referred for PT and OT due to physical deconditioning. Review of the initial comprehensive assessment completed on 1/19/24, showed the DOR inaccurate assessed Patient #3's endocrine system. Specifically, the DOR documented Patient #3 had no problems identified in her endocrine system, failing to identify Patient #3's diagnosis of type 2 diabetes mellitus and to assess how Patient #3 managed her type 2 diabetes mellitus. b) The agency failed to ensure an accurate resumption of care comprehensive assessment was completed for Patient #3. Specifically, the DOR failed to list all of Patient #3's diagnosis appropriate to this episode of care and failed to accurately assess Patient #3's endocrine system and cardiac status. Review of the resumption of care comprehensive assessment completed on 2/26/24, showed the DOR inaccurately completed the diagnosis section of the assessment. Specifically, the DOR documented Patient #3's primary diagnosis for the initiation of this home care episode was hypothyroidism and other diagnoses included hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, and other malaise. The DOR failed to document the diagnosis found on Patient #3's referral documentation after her hospitalization. Review of referral documentation sent to the agency on 2/19/24, by the skilled nursing facility (SNF) who cared for Patient #3 from 1/27/24 through 2/22/24 (Patient #3 was hospitalized from 1/23/24 through 1/27/24), showed Patient #3's was assessed by a physician at the SNF on 2/9/24. The physician at the SNF documented Patient #3 had been admitted to the hospital with Influenza A, a pulmonary embolism (blood clot in her lung) and bilateral lower extremity deep vein thrombosis (blood clots in her legs), and acute respiratory failure with hypoxia (low blood oxygen). The physician at the SNF listed Patient #3's pertinent medical history included: hypertension, type 2 diabetes mellitus controlled with diet, gastroesophageal reflux, stage 4 chronic kidney disease, gout, hyperlipidemia, unspecified glaucoma, muscle weakness and multiple orthopedic issues. Additionally, the referral documentation listed the medication Patient #3 was taking, which included the anticoagulant (blood thinner) Apixaban 5 milligrams by mouth daily. c) The agency failed to ensure on 3/16/24, an accurate recertification comprehensive assessment was completed for Patient #3. Specifically, the DOR failed to accurately assess Patient #3's endocrine system and cardiac status. Review of the resumption of care comprehensive assessment completed on 3/16/24, showed the DOR inaccurately assessed Patient #3's endocrine system. Specifically, the DOR documented Patient #3 had no problems identified in her endocrine system, failing to identify Patient #3's diagnosis of type 2 diabetes mellitus and to assess how Patient #3 managed her type 2 diabetes mellitus. Review of the resumption of care comprehensive assessment completed on 3/16/24, showed the DOR inaccurately assessed Patient #3's cardiac status. Specifically, the DOR documented Patient #3 was not taking an anticoagulant medication, failing to identify Patient #3 was taking the anticoagulant medication Apixaban. 2. During an interview on 5/1/24 at 10:26 a.m., Patient #3 stated her current diagnoses were: type 2 diabetes, hypertension, gout, chronic kidney disease, high cholesterol, and gastric reflux. Patient #3 stated her kidney doctor was currently running tests to see if she was suffering from hypothyroidism, but she did not have a current diagnosis of hypothyroidism. Patient #3 stated she took several medications daily which included: lasix (a diuretic) for her kidney issues, omeprazole for her gastric reflux, latanoprost eye drops to prevent glaucoma, high blood pressure medicine, high cholesterol medication, Vitamins C, D, and E, and Eliquis (the brand name for Apixaban) to prevent her from getting any more blood clots. Patient #3 stated she had been taking Eliquis since the end of February 2024 when she discharged home from the SNF. During an interview on 5/2/24 at 9:57 a.m., the DOR acknowledged she completed Patient #3's start of care comprehensive assessment on 1/19/24, her resumption of care comprehensive assessment on 2/26/24 and her recertification comprehensive assessment on 3/16/24. The DOR stated Case Managers #11 and #15 were responsible for documenting a patient's diagnoses on a patient's comprehensive assessment. The DOR stated she could not recall the reason Patient #3 was hospitalized in January of 2024 and required a resumption of care comprehensive assessment on 2/26/24 as it was too many months ago. The DOR stated she was out of the country on vacation and could not access the agency's electronic medical record (EMR) system to be able to review the documentation to assist her with her recall of events. The DOR stated her practice when she completed any comprehensive assessment was to review the referral documentation sent to the agency. Additionally she would review a patient's medication list and compare this to the medications the patient had in their home. If there was any discrepancies in the medication list compared to the medication the patient had in the home, she would notify the patient's physician and the agency management staff to get the discrepancies corrected. During an interview on 5/2/24 at 10:22 a.m., Case Manager #11 reviewed Patient #3's comprehensive assessments and referral documentation and agreed the primary diagnosis of hypothyroidism was inaccurate. Case Manager #11 stated per the initial referral documentation sent to the agency on 1/17/24 the primary diagnosis listed should have been hypertension. The director of nursing (DON) reviewed the 1/17/24 referral information and the comprehensive assessments and stated due to Patient #3's type 2 diabetes, the DOR should not have marked no problem identified on the endocrine section of the assessment. The DON stated the DOR should have marked Patient #3 had type 2 diabetes mellitus and completed the assessment questions related to this diagnosis. The DON also reviewed the referral information sent to the agency on 2/19/24, the resumption of care comprehensive assessment completed on 2/26/24, and the recertification comprehensive assessment completed on 3/16/24 by the DOR and stated the DOR should have checked Patient #3 was taking an anticoagulant medication. During continued interview, Case Manager #11 stated the agency had noted when a therapist completed a comprehensive assessment they tended to focus primarily on the issues the therapist would address for the patient and sometimes failed to complete a full comprehensive assessment for the patient. Case Manager #11 stated the agency had started to ask physician's on a therapy only case if a registered nurse could have orders to complete the initial assessment, to ensure the patient received a complete comprehensive assessment.

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 observation, interview and record review the agency failed to ensure drugs, services and treatments were administered only as ordered by a physician or allowed practitioner for 4 of 9 active patient records reviewed (Patients #3, #4, #5, and #8). Findings include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Patient Assessments/ Plan of Care, (read in pertinent parts): "Physician's orders are established, and documented, for the health care services the agency provides to those patients who: -Are being actively treated, by a physician, for a diagnosed health care problem. -Have a health care need, or change[,] in physical status, requiring medical intervention. - Are Home Health Aide patients of a certified Home Health Agency." "Any changes in the physician's plan of treatment shall be made, in writing, and signed, timed, and dated by the physician, or by the registered nurse [on] the staff of the Agency, pursuant to the verbal orders of the physician, which will be mailed to him for his signature and place in the chart, within 30 days." 1. The clinical record for Patient #5 was reviewed on 4/30/24. The plan of care for the certification period dated 3/13/24 to 5/11/24, and signed by Patient #5's primary care physician (PCP) on 4/22/24, revealed a start of care date of 3/13/24; diagnoses included: stage 4 pressure ulcers of right and left heels and other site, stage 3 pressure ulcer of right ankle, unstageable pressure ulcer of the left ankle, osteomyelitis of right ankle and foot, alcohol abuse, alcoholic polyneuropathy, nicotine dependence, esophagitis, and anemia. Plan of care orders included skilled nurse (SN) visits two times a week for one week and three times a week for eight weeks for wound care; and physical therapy (PT) to evaluate and treat. a) The agency failed to obtain orders for the SN care provided to Patient #5 from 3/15/24 through 3/26/24, a total of four SN visits. Review of a referral order sent to the agency on 3/13/23 at 1:13 p.m., showed an order for home health for wound care evaluation and treatment. Review of Patient #5's supplemental orders showed on 3/13/24, registered nurse (RN) #16 documented Patient #5's start of care (SOC) assessment was completed. RN #16 requested SN visits two times a week for one week and three times a week for eight weeks for wound care. RN #16 requested the specific wound care she recommended the agency's SN perform with Patient #5 was as follows: clean areas with wound cleanser; pat dry; apply medi-honey (a wound gel that provides a moist wound environment and autolytic debridement of a wound) to the wound bed; cover the area with calcium alginate (a type of wound dressing used to promote new cell formation); cover with a non-stick dressing and secure with kerlix (a type of rolled gauze). RN #16 requested orders for PT to eval and treat on 3/25/24. By the time of the survey exit, this order had not been signed by Patient #5's PCP. Review of Patient #5's journal notes from 3/13/24 through 4/25/24 showed on 3/14/24 at 9:14 a.m. Case Manager #11 documented she tried to call Patient #5's PCP office to obtain verbal orders to continue Patient #5's care based on RN #16 recommendations. Case Manager #11 documented she was only able to leave a voicemail requesting a call back. Review of a journal note written on 3/14/24 at 10:11 a.m. by Intake Coordinator #14 showed Patient #5's PCP returned the agency's phone call. Patient #5's PCP declined to provide a verbal order for Patient #5. Intake Coordinator #14 stated Patient #5's PCP's office stated Patient #5 was scheduled for a visit with the PCP on 3/25/24. Intake Coordinator #14 documented Patient #5 could call her PCP to try to get her visit moved up from 3/25/24. Review of a journal note written on 3/14/24 at 10:52 a.m., showed Case Manager #11 attempted to reach Patient #5 and her spouse, but neither Patient #5 or her husband answered the telephone. Case Manager #11 documented she left a voice message requesting Patient #5 call the agency back regarding her 3/25/24 PCP appointment. Review of a text communication between agency employees regarding Patient #5 showed on 3/14/24 at 11:18 a.m., Intake Coordinator #14 documented Patient #5 received the message from the agency regarding Patient #5's PCP declining to give a verbal order until Patient #5 was seen by her PCP. Intake Coordinator #14 documented Patient #5 stated she would contact her PCP right away. Review of a text communication between agency employees regarding Patient #5 showed on 3/14/24 at 2:59 p.m., Intake Coordinator #14 documented Patient #5 was scheduled to see a colleague of her PCP (her PCP was on vacation) on Monday (3/18/24) instead of Monday 3/25/24 and the agency could call again on Monday (3/18/24) to obtain a verbal order for continued SN visits and the specific wound care to perform for Patient #5. Review of text communications between agency employees regarding Patient #5 showed on 3/15/24, licensed practical nurse (LPN) #17 requested information from agency management regarding what the specific wound care orders were for Patient #5. RN #16 documented there were no wound care orders as Patient #5 needed to follow up with her PCP to obtain orders. Case Manager #11 asked if RN #16 could recommend any wound care and asked if RN #16 called Patient #5's PCP. RN #16 documented Patient #5 needed to see her PCP first, but LPN #17 could do medi-honey and calcium alginate and cover with non-stick dressing and wrap with kerlix. Case Manager #11 requested RN #16 create a verbal order for her wound care recommendations. Review of a text communication between agency employees regarding Patient #5 on 3/18/24 at 10:04 a.m. showed Intake Coordinator #14 documented Patient #5's PCP still could not provide the verbal order for continued SN care and the specific wound care orders requested by the agency, as Patient #5 failed to show up for her scheduled appointment. Patient #5's PCP office stated Patient #5 still had an appointment with her PCP on 3/25/24. Review of a text communication between agency employees regarding Patient #5 showed on 3/26/24, Case Manager #11 received an order for wound care for Patient #5 and requested RN #16 add this order to Patient #5's interventions by creating a change order. Review of the 3/25/24 wound care order received by the agency on 3/26/24 at 2:03 p.m., showed Patient #5 was to receive home health SN for wound care three times a week and home health PT. Review of SN notes from 3/13/24 to 4/29/24, showed LPN #17 provided Patient #5 with SN care including wound care on 3/15/24, 3/18/24, 3/20/24 and 3/22/24: all four visits were provided without orders. During a home visit on 5/1/24 at 12:40 p.m., LPN #17 acknowledged her first visit with Patient #5 was on 3/15/24. LPN #17 stated Patient #5 had five wounds and LPN #17 measured all five wounds, documented the measurements of Patient #5's five wounds in the agency's EMR and provided wound care as indicated in the intervention section of the EMR. LPN #17 acknowledged she provided Patient #5 care on 3/18/24, 3/20/24, and 3/22,25 as well. During an interview on 5/2/24 at 8:59 a.m., RN #16 stated she called Patient #5's PCP office on 3/13/24 and attempted to receive a verbal order to continue care of Patient #5 and to receive specific orders for wound care as the referral order the agency received was for wound care evaluation and treatment. RN #16 stated Patient #5's PCP refused to provide verbal orders for Patient #5 until the PCP saw Patient #5. RN #16 stated Patient #5 had an appointment with her PCP on 3/25/24, and the agency was provided orders to proceed with SN three week for wound care with specific instructions provided for Patient #5's left and right foot and leg wounds on 3/26/24.. RN #16 stated she did not know why LPN #17 was scheduled to provide visits from 3/15/24 through 3/22/24 as the agency did not have orders for that care. During an interview on 5/2/24 at 11:26 a.m., the director of nursing (DON) and Case Manager #11 both acknowledged the agency provided Patient #5 with wound care on 3/15/24, 3/18/24, 3/20/24 and 3/22/24 without having orders. The DON and Case manager #11 stated the administrator directed Case Manager #11 to schedule LPN #17 to provide the care for Patient #5 without orders on those four days as Patient #5's PCP would not provide them with verbal orders until Patient #5 was seen by the PCP. The DON and Case Manager #11 stated the administrator was worried about Patient #5 potentially developing an infection if she was not provided any wound care until she was seen by her PCP, thus the administrator decided to have LPN #17 continue to provide Patient #5 with wound care; and follow the wound care orders Patient #5 was provided in the long-term acute care hospital prior to discharging home. During an interview on 5/2/24 at 2:42 p.m., the administrator acknowledged she advised the DON and Case Manager #11 to have LPN #17 provide Patient #5 with wound care without orders on 3/15/24, 3/18/24, 3/20/24 and 3/22/24. The administrator stated she directed her management staff to make this decision as she was worried about the health consequences Patient #5 might face if the wound care was not provided. The administrator stated she recently had another patient whose PCP would not provide verbal orders for wound care and the agency did not provide that patient wound care until the orders were received. The administrator stated the patient developed an infection in her wound. The administrator acknowledged regulation required the agency to have physician orders for all care provided. b. The agency failed to ensure LPN #17 followed wound care orders for treatment provided to Patient #5 from 3/27/24 through 5/1/24, a total of 13 visits. Further review of the 3/25/24 wound care order received at the agency on 3/26/24 for Patient #5 showed Patient #5's right heel wound was to be cleansed with saljet (a bullet of saline used to cleanse wounds), gauze, and wound cleanser and dressed with Sureprep to periwound (a product used on skin around a wound to create a protective barrier), alginate, foam and offload, conforming gauze and Coban (a type of self stick bandage). Patient #5's left heel and left lateral wound were to be: cleansed with gauze and wound cleanser; dressed with Sureprep to the periwound; allevyn (a type of wound dressing that provides a barrier to bacteria and helps prevent fluid from leaking) with one large allevyn for Patient #5's heel and a small one for her lateral wound; and wrapped in conforming gauze and Coban. Review of SN notes from 3/27/24 through 4/29/24 showed LPN #17 documented she provided Patient #5 with wound care as ordered on the 3/25/24 wound care order. During a home visit on 5/1/24 at 12:11 p.m., LPN #17 was observed to provide Patient #5's Left and Right heels and left lateral leg wound with the following wound care: removal of the old dressing; cleansed each wound with wound cleanser and gauze; applied skin prep to the periwound of each wound; applied an alginate dressing with medi-honey on the alginate cut to the size of each of the three wounds; assisted the alginate dressings to stay in place by wrapping both Patient #5's right and left foot and lower leg with kerlix, and then secured the kerlix with Coban. LPN #17 failed to follow the wound care orders for Patient #5's Left and right lower extremity wounds provided to the agency on 3/26/24. During an interview on 5/1/24 at 12:40 p.m., LPN #17 showed the surveyors in the agency's electronic medical record (EMR) where she looked to see what wound care orders to provide a patient. LPN #17 showed the surveyors the wound care request order entered into the agency EMR on 3/13/24 by RN #16. LPN #17 stated the wound care the surveyors observed LPN #17 provide Patient #5 on 5/1/24, was the wound care she had provided to Patient #5 since she began caring for her on 3/15/24. LPN #17 stated she was not aware Patient #5's wound care orders had changed on 3/26/24, thus she failed to provide the wound care as ordered for all 13 visits she provided Patient #5 from 3/27/24 through 5/1/24. LPN #17 stated she failed to see the 3/26/24 wound care order in the system. During an interview on 5/2/24 at 8:59 a.m., RN #16 stated the change in Patient #5's wound care order on 3/26/24 was communicated to all SNs who provided Patient #5 care, including LPN #17, in the text communication chain the agency used to communicate regarding Patient #5. Additionally, RN #16 stated she completed a change order in the system to update the interventions for the wound care to provide Patient #5 on 3/26/24, and LPN #17 would be able to see updated wound care interventions in the agency's EMR. RN #16 could not state why LPN #17 had not seen the wound care order changes on 3/26/24 or why she did not follow the new orders. During an interview on 5/2/24 at approximately 3:00 p.m., the administrator and DON stated they were not aware LPN #17 was not following the wound care orders provided to the agency on 3/26/24 and instead 3/15/24 through 5/1/24 had provided Patient #5 with the wound care order requested by RN #16 on 3/13/24. The administrator stated LPN #17 should have followed the 3/25/24 order received by the agency on 3/26/24 and updated in the agency's EMR by RN #16 on 3/26/24. 2. The clinical record for Patient #3 was reviewed on 4/29/24. The plan of care for the certification period dated 1/19/24 to 3/18/24, revealed a start of care date of 1/19/24; diagnoses included: hypothyroidism, hypertension, stage 4 chronic kidney disease, gout, polyneuropathy, malaise and history of falling. Plan of care orders included PT visits one time a week for one week, two times a week for three weeks and one time a week for four weeks starting on 1/19/24 for strengthening, transfer training, gait training, endurance training, and fall risk assessment and education; occupational therapy (OT) one time a week for one week starting 1/21/24 for evaluation and treatment. a) The agency failed to obtain a delayed resumption of care (ROC) order for Patient #3 when she returned home from the hospital on 2/22/24. Review of Patient #3's record revealed the director of rehab (DOR), PT #5, completed a transfer to inpatient facility (TIF) OASIS on 1/23/24 for Patient #3 which stated Patient #3 was admitted to the hospital on 1/23/24 for an unknown reason. Review of discharge paperwork, faxed to the agency on 2/19/24, from the skilled nursing facility Patient #3 was admitted to from the hospital on 1/27/24, showed Patient #3 was discharged home to her new living environment, a senior living facility, on 2/22/24. The paperwork showed the agency was ordered to provide home health PT and OT to Patient #3. Review of Patient #3's record showed text communications between employees for Patient #3 from 2/19/24 to 2/26/24. On 2/21/24, Scheduler #13 documented Patient #3 wanted to move her ROC comprehensive assessment scheduled for 2/23/24 and the address of Patient #3's new senior living facility. Scheduler #13 failed to document further information regarding what day Patient #3 requested to move her ROC comprehensive assessment appointment to. On 2/22/24 at 8:01 a.m., Scheduler #13 documented Patient #3 wanted her ROC comprehensive assessment appointment to be on Monday, 2/26/24, and Scheduler #13 included a screenshot of a text sent to him by Patient #3 on 2/21/24 at 6:27 p.m., in which Patient #3 texted she wanted to wait until Monday, 2/26/24 for her ROC comprehensive assessment. On 2/22/24 at 8:02 a.m., Scheduler #13 documented he would call to obtain a delayed ROC order. On 2/22/24 at 11:55 a.m., Scheduler #13 documented he spoke with an employee at Patient #3's PCP office and requested a delayed ROC order. Scheduler #13 documented he expected a call back on 2/23/24 to receive the delayed ROC order. Review of Patient #3's record revealed the DOR completed Patient #3's ROC OASIS/comprehensive assessment on 2/26/24. Review of Patient #3's record failed to reveal the agency had obtained a verbal or written order to delay completing Patient #3's ROC comprehensive assessment within 48 hours of her return home from the hospital as required by regulation. During an interview on 5/2/24 at 9:52 a.m., the DOR stated the agency's expectation was ROC comprehensive assessments would be completed within 48 hours of a patient returning home from the hospital unless a delayed ROC order was obtained. The DOR stated she was out of the country on a vacation and could not access the agency's EMR system. The DOR stated she could not recall why Patient #3's ROC comprehensive assessment in February 2024 was delayed or if a delayed ROC order was obtained. During an interview on 5/2/24 at 10:33 a.m., the DON and Case Manager #11 reviewed Patient #3's record and acknowledged the agency failed to obtain a delayed ROC order for Patient #3. Case Manager #11 stated typically the clinician going out to complete the ROC was responsible for obtaining the delayed ROC order for a patient. Case Manager #11 stated Scheduler #13 called to request a delayed ROC order, but failed to document if he received approval from Patient #3's PCP for the agency to delay Patient #3's ROC. Case Manager #11 reviewed the text messages agency employees had regarding Patient #3 and stated could she could not say why the agency failed to obtain the delayed ROC order for Patient #3. 3. The clinical record for Patient #4 was reviewed on 4/30/24. The plan of care for the certification period dated 4/6/24 to 6/4/24, revealed a start of care date of 4/6/24; diagnoses included: malignant neoplasm of the unspecified bronchus or lung, stage 1 pressure ulcer of the sacral region; chronic pain, hypertension, chronic obstructive pulmonary disease, muscle weakness, obstructive sleep apnea, disorders of psychological development, constipation, nausea and vomiting, repeated falls, anxiety, and history of a femur fracture. Plan of care orders included SN visits five times a week for eight weeks for assessment and wound care starting from 4/15/24; and home health aide (HHA) visits three times a week for nine weeks for assistance with bathing and grooming starting 4/8/24. Review of Patient #4's supplemental orders revealed a verbal order for daily SN visits for daily sacral wound dressing changes for Patient #4's coccyx wound and HHA visits three times a week to assist with showering and grooming written by RN #10 on 4/8/24 and signed by Patient #3's PCP on 4/25/24. a) The agency failed to ensure SN visits were completed as ordered. Review of Patient #4's clinical record revealed from 4/6/24 through 4/29/24 Patient #4 received 15 SN visits on the following days: 4/6/24, 4/10/24, 4/11/24, 4/15/24 - 4/19/24, 4/21/24, 4/22/24, 4/24/24 - 4/26/24, 4/28/24 and 4/29/24. Patient #4 had documented missed SN visits sent to his PCP on 4/9/24, 4/12/24, and 4/23/24. Further record review failed to show why Patient #4 did not receive SN visits on the following five days: 4/8/24, 4/13/24, 4/14/24, 4/20/24, and 4/27/24. During a home visit on 4/30/24 at 8:41 a.m., Patient #4 stated RN #10 provided him SN care five or six days a week for wound care. Patient #4 stated he typically received SN visits Monday through Friday and sometimes on Sunday. Patient #4 stated he did not know why he didn't receive SN visits on Saturdays and why he only sometimes received SN visits on Sundays. During an interview on 5/1/24 at 3:35 p.m., RN #10 confirmed she was Patient #4's primary nurse. RN #10 stated she provided Patient #4 with assessment and wound care Monday through Fridays and as needed (PRN) visits on the weekends. RN #10 reviewed the verbal order she obtained on 4/8/24 from Patient #4's PCP in which she documented Patient #4's PCP provided her with an order for daily SN visits for wound care. RN #10 stated daily meant seven days a week. RN #10 stated she could not recall exactly what she requested from Patient #4's PCP for a SN frequency. RN #10 stated what she wanted to request and should have documented was SN visits Monday through Friday with PRN visits on Saturdays and Sundays. RN #10 acknowledged the verbal order she documented and was signed by Patient #4's PCP was for daily SN visits. RN #10 stated the she had failed to comply with this order as Patient #4 did not receive SN visits for five days from 4/8/24 through 4/29/24. During an interview on 5/2/24 at 11:11 a.m., Case Manager #11 stated part of her job responsibility was to ensure SN visits were scheduled as ordered to ensure visits were not missed. Case Manager #11 stated the start of care order for Patient #4 was for SN visits five times a week and she scheduled SN visits for five times a week. Case Manager #11 stated she had just recently seen RN #10 had obtained a verbal order for daily SN visits, and by that point, Patient #4 had not received the five missed visits. Case Manager #11 stated she educated RN #10 on the importance of ensuring her frequency of visits matched her order. Case Manager #10 also stated she re-educated RN #10 on the importance of remembering to update the text communication thread agency employees used to discuss patients, including scheduling issues, to ensure all agency employees were informed of changes with a patient. 4. Similar findings of the agency failing ensure SN visits were completed as ordered was found for Patient #8. 5. During an interview on 5/2/24 at 11:49 a.m., Case Manager #11 stated the agency needed to improve their process of having clinicians verify the agency received an order when a member of the team requested an order from a physician prior to the clinician providing the care. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure verbal orders were documented in the patient's record by the skilled nurse (SN) who received the order for 2 of 9 active patients records reviewed (Patients #4 and #7). Findings include: AGENCY POLICY According to an agency policy, dated 2019, and titled, Verbal Orders, (read in pertinent parts): "Physician's orders, which are signed, timed, and dated by the physician, are required for all services rendered by the Agency. All verbal, or telephone, orders will be received by licensed personnel, i.e., RN [registered nurse], PT [physical therapist], ST [speech therapist], OT [occupational therapist], etc. All Plans of Care/Treatment and verbal, or telephone, orders will be countersigned, by the physician, within thirty (30) days. Verbal orders are to be recorded in the patient's clinical record, by the professional receiving them and must include date, time, and signature." 1. During an interview on 4/29/24 at 10:19 a.m., the administrator stated the clinician who received a verbal order from the patient's physician was responsible for documenting the verbal order in the patient's record. The administrator stated the clinician was to document the order, the name of the person at the physician's office who provided the order, the time and date the order was received; and the clinician was to sign the order. The administrator stated agency personnel who worked in the office were responsible for sending all verbal orders to the physician who provided the order to the physician to authenticate, sign and date the verbal order. 2. The clinical record for Patient #4 was reviewed on 4/30/24. The plan of care for the certification period dated 4/6/24 to 6/4/24, revealed a start of care date of 4/6/24; diagnoses included: malignant neoplasm of the unspecified bronchus or lung, stage 1 pressure ulcer of the sacral region; chronic pain, hypertension, chronic obstructive pulmonary disease, muscle weakness, obstructive sleep apnea, disorders of psychological development, constipation, nausea and vomiting, repeated falls, anxiety, and history of a femur fracture. Plan of care orders included SN visits five times a week for eight weeks for assessment and wound care starting from 4/15/24; and home health aide (HHA) visits three times a week for nine weeks for assistance with bathing and grooming starting 4/8/24. Further review of the plan of care showed SNs were to apply calmoseptine cream (a multipurpose moisture barrier that protects and helps heal skin irritations) to Patient #4's coccyx wound and to cover the wound with a mepilex border foam dressing (a conformable antimicrobial foam dressing that absorbs drainage and maintains a moist wound environment). a. The agency failed to ensure registered nurse (RN) #10 documented all verbal orders received for Patient #4's wound care. Review of Patient #4's 4/6/24 start of care outcome and assessment information set (OASIS)/comprehensive assessment showed RN #10 assessed Patient #4 to have one stage 1 pressure ulcer on his coccyx. Review of Patient #4's wound care assessment in the agency's electronic medical record (EMR) showed on 4/6/24, RN #10 assessed Patient #4 to have a stage 1 pressure ulcer to his coccyx which RN #10 labeled Site 1. On 4/16/24, RN #10 assessed Patient #4 to have an additional stage 1 pressure ulcer at his gluteal fold, which she labeled Site 2. On 4/29/24, RN #10 assessed Patient #4 to have a stage 1 pressure ulcer on his sacrum, which she labeled Site 3 and she documented Patient #4's Site 1 wound was healed. Review of a SN note dated 4/16/24, showed RN #10 documented, in the today's notes section of the note, she discovered Patient #4 had a new open area. RN #10 documented she updated Patient #4's wound care assessment. RN #10 stated she contacted a medical doctor (MD), the note failed to state which MD, and received a verbal order to treat the new wound (Site 2) with the same treatment (cover the wound with caloseptime cream and a mepilex dressing) as Patient #4's Site 1 wound. Patient #4's record failed to show RN #10 documented the verbal order she received on 4/16/24 that included: the name of physician and/or the physician representative she received the verbal order from, the date and time she received the verbal order and her signature. Review of Patient #4's wound care assessment documentation from 4/16/24 to 4/28/24 showed RN #10 documented she provided wound care as ordered to Patient #4's Site 1 and 2 wounds. Review of a SN note dated 4/29/24, showed RN #10 documented, in the today's notes section of the note, she discovered Patient #4 had developed a new open area to his sacrum area (labeled Site 3 on the wound care assessment) below the coccyx and Patient #4's coccyx wound was healed. RN #10 documented a MD (RN#10 failed to document the name of the MD she spoke to) recommended the same treatment for the new open area. Patient #4's record failed to show RN #10 documented the verbal order she received on 4/29/24 to treat Patient #4's new sacral wound that included: the name of physician and/or the physician representative she received the verbal order from, the date and time she received the verbal order and her signature. During an interview on 5/1/24 at 3:03 p.m., RN #10 confirmed she was the SN who completed Patient #4's start of care assessment and provided him with SN visits most days. RN #10 stated on 4/16/24 and 4/29/24 she called Patient #4's primary care physician (PCP) to inform the PCP that Patient #4 had developed a new wound each of those days. RN #10 stated the PCP provided her with a verbal order to provide the same wound care treatment of cover the wound with caloseptime cream and a mepilex dressing as provided for Patient #4's initial coccyx wound on 4/6/24, but she failed to document the verbal orders she received on 4/16/24 and 4/29/24. RN #10 stated the agency expectation was all verbal orders received were to be documented in the patient's record as a verbal order. RN #10 stated she forgot to document the verbal orders she received on 4/16/24 and 4/29/24. RN #10 stated she was still learning how to use the agency's EMR. RN #10 also stated she often forgot to document; and was working on improving her documentation as she was aware of how important it was to document. During an interview on 5/2/24 at Case Manager #11 acknowledged RN #10 failed to document the 4/16/24 and 4/29/24 verbal orders she received for wound care for Patient #4's Site 2 and 3 wounds respectively. Case Manager #11 stated part of her responsibilities at the agency was to complete quality assurance reviews of patient's records which included, but was not limited to, ensuring SNs and/or therapists documented all verbal orders received. Case Manager #11 stated she noted RN #10 had failed to document the verbal order she received for wound care to Patient #4's Site 2 wound on 4/16/24 and had reminded RN #10 to document the verbal order. Case Manager #11 acknowledged as of 5/2/24, RN #10 had failed to document the 4/16/24 verbal order and Case Manager #11 had failed to follow up and ensure RN #10 completed this task. 3. Similar findings of the agency failing to ensure SNs documented all verbal orders received was found for Patient #7. 4. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.

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 interview and record review the agency failed to ensure the home health aide (HHA)/certified nursing assistant (CNA) provided services as ordered by the physician, included in the plan of care and permitted under State Law for 1 of 4 active patient records reviewed receiving HHA services (Patient #1). Findings include: AGENCY POLICY According to an agency policy dated 2019 and titled, Home Health Aide Service, (read in pertinent parts): "A Home Health Aide provides services that are: -Ordered by the physician; -Included in the plan of care; -Permitted to be performed under state law; and -Consistent with the home health aide training." 1. The clinical record for Patient #1 was reviewed on 4/29/24. The plan of care for the certification period dated 3/14/24 to 5/12/24, revealed a start of care date of 3/20/23; diagnoses included: type 2 diabetes mellitus, chronic obstructive pulmonary disease, hypertension, glaucoma, benign prostatic hyperplasia, disorders of pituitary gland, insomnia, anxiety, alcohol abuse, gastro-esophageal reflux, tremor, amnesia and essential tremor. Plan of care orders included: skilled nurse (SN) visits two times a week for nine weeks for medication management, set up, and compliance; oxygen safety checks; assessment; and disease management; and HHA visits two times a week for nine weeks for grooming and showering assistance. a) The agency failed to ensure HHA #7 only provided services as ordered by the physician, included in the plan of care and permitted under state law. Specifically, the agency failed to ensure HHA #7 did not cut Patient #1's fingernails or toenails. Review of the HHA care plan dated 3/14/24 to 5/12/24 revealed the HHA #7 was assigned to assist Patient #1 with shampooing and showering without a frequency provided. Review of HHA visit notes from 3/14/24 to 4/30/24 revealed HHA #7 provided Patient #1 with care nine times (3/18/24, 3/22/24, 3/25/24, 3/28/24, 4/1/24, 4/8/24, 4/22/24, 4/30/24). During an interview on 4/30/24 at 4:16 p.m., HHA #7 stated she reviewed a patient's plan of care when she first began to provide a patient care, in order to know what tasks to assist the patient with. HHA #7 stated she confirmed the information she reviewed on the plan of care with the patient prior to starting services. During a home visit on 4/30/24 at 12:24 p.m., Patient #1 and HHA #7 confirmed she was Patient #1's HHA and provided Patient #1 with care two times a week for grooming and hygiene. HHA #7 specifically stated she assisted Patient #1 to shower and she assisted Patient #1 with cutting his fingernails and toenails as needed, a task not ordered by the physician, care planned or permitted under state law due to Patient #1 being diabetic. HHA #7 stated she used large clippers to cut Patient #1's toenails as he had thick toenails and it took her awhile to cut his nails. HHA #7 stated she was not aware Patient #1 suffered from type 2 diabetes. During an interview on 5/2/24 at 11:55 a.m., the director of nursing (DON) stated she was unaware HHA #7 was cutting Patient #1's fingernails and toenails. The DON stated this task was not ordered by Patient #1's physician for the HHA to perform, care planned or permitted under state law due to Patient #1's type 2 diabetes. The DON stated fingernail and toenail trimming was not a care planned task or permitted under state law for a HHA to perform on a patient with diabetes because if the HHA were to accidentally cut the patient's skin with the nail clippers, the patient could develop a wound. The DON stated this would be a potential issue for a patient with diabetes as diabetes can impede a patient's ability to heal a wound. The DON stated HHA #7 had access to Patient #1's plan of care which stated Patient #1 had type 2 diabetes, thus HHA #7 should have been aware Patient #1 had type 2 diabetes. The DON stated the agency educated all HHA that fingernail and toenail trimming was not a HHA permitted task for patients with diabetes. The DON also stated, HHA #7 should only provide patients assistance with care planned tasks. The DON stated she would re-educate HHA #7 on the importance of reviewing a patient's diagnosis and only providing care planned and permitted tasks with patients. 2. During an interview on 5/2/24 at 3:06 p.m., the administrator stated she appreciated the survey process as the agency always learned so much through the process. The administrator stated the agency strived to provide good care to their patients and would work to correct the deficient practice cited during this survey.

A complaint survey prompted by #CO62993 was completed on 5/10/22. Based on interview and record review, the agency accepted a patient referral and had assumed care and services to provide post surgical wound assessment and treatment, medication and disease management, and laboratory blood draws to test for the international normalized ratio (INR). The agency failed to coordinate care with the physician by not receiving a verbal order for delaying the start of care, and delaying a necessary INR blood draw which resulted in Patient #1 requiring services at a hospital for an INR level of 10.7. The agency failed to dispatch a registered nurse (RN) to conduct a start of care assessment and provide an INR blood draw and post surgical wound assessment and treatment for seven days following receipt of the referral on 4/26/22. One condition-level deficiency was cited. 484.60 Care Planning, Care Coordination and Quality of Care. Additionally, six 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.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency abruptly discharged a patient without evidence of efforts to resolve the problem(s) presented by the patient’s behavior. This failure occurred for 1 of 6 patients admitted to the agency reviewed (Patient #10). Findings included: AGENCY POLICY: According to agency policy 5.21 titled “Transfer & Discharge Policy” (undated, in pertinent parts), “Discharge for Cause: The agency determines, under a policy set by the agency, for the purpose of addressing discharge for cause that the patient’s behavior is disruptive, abusive or uncooperative, to the extent that delivery of care to the patient, or the ability of the agency to operate effectively, the agency must make effort to resolve the problem(s) presented, provide the patient with contact information for other agencies, or providers, who may be able to provide care; and document the efforts made to resolve the problem(s) into the clinical record. A plan shall be developed, or a referral made, for any continuing care indicated,” 1. The clinical record for Patient # 6 was reviewed on 5/9/22. The Plan of Care for the certification period dated 4/20/22 to 6/18/22 revealed a start of care date of 4/20/22. Plan of Care orders included skilled nursing (SN) three times per week for assessment, pain management, medication safety, nutrition, hydration, infection, surgical incision and wound care, including dressing and wound vacuum-assisted closure (VAC, a device used to help assist with wound healing) changes on Monday, Wednesday and Friday. Further review of the Plan of Care revealed no relevant patient diagnoses were included. The primary, surgical and other diagnoses sections of the Plan of Care were left blank. However, review of the comprehensive assessment completed by the agency registered nurse (RN) #6 on 4/20/22 revealed the patient had diagnoses that included a puncture wound to the abdomen, open wound, infection, pain, and post-surgical complications. a) The agency failed to ensure they made an effort to help resolve problems presented by the patient's behavior after the patient texted inappropriate messages to the agency SN prior to a scheduled SN visit. Continued review of the clinical summary in the Plan of Care completed by RN #6 on 4/21/22 revealed Patient #10 was admitted by the agency on 4/20/22 with a need for a SN to provide wound management after the patient had sustained a trauma to the abdominal area that resulted in postoperative complications. The clinical summary also noted the patient lived alone in a second story apartment, without additional support. Review of a communication log contained in Patient #10’s electronic health record (EHR) showed SN #7 had contacted licensed practical nurse (LPN) #3 to complain about the patient's inappropriate text messages she had received on 4/22/22 after she had contacted the patient to arrange a time for a scheduled SN visit. SN #7 further documented she was uncomfortable providing care for the patient as a result. Continued review of the communication log showed LPN #3 entered a communication note on 4/25/22 that noted Patient #10 was informed that the agency would no longer be able to provide wound care due to the patient being inappropriate with the clinician and was advised to contact his primary care provider for further instructions regarding care. Further record review revealed an agency staff member had obtained a verbal order from Patient #10’s physician of record on 4/22/22 at 2:15 p.m. to discharge Patient #10 from the agency due to being inappropriate with clinicians on multiple occasions. The verbal order was not signed by an agency clinician. Continued record review revealed no evidence the agency had contacted the patient to discuss the inappropriate text messages or attempt to resolve the inappropriate behavior displayed by Patient #10 prior to the abrupt discharge. During an interview on 5/10/22 at 3:00 p.m., with both the agency administrator and LPN #3 present, LPN #3 stated she had contacted Patient #10 and advised him he was being discharged from the agency, however she made no attempt to investigate or resolve the behavior prior to discharge. During the same interview on 5/10/22 at 3:00 p.m, the administrator stated it was agency policy to investigate the problem(s) and get both sides. The administrator acknowledged she was aware no one from the agency had contacted the patient to attempt to resolve the conflict prior to the abrupt discharge.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency abruptly discharged a patient without evidence of efforts to provide the patient with contact information for other agencies or providers who may be able to provide care. This failure occurred for 1 of 6 patients admitted to the agency reviewed (Patient #10). Findings included: AGENCY POLICY: According to agency policy titled “Transfer & Discharge Policy” (undated, in pertinent parts), “Discharge for Cause: The agency determines, under a policy set by the agency, for the purpose of addressing discharge for cause that the patient’s behavior is disruptive, abusive or uncooperative, to the extent that delivery of care to the patient, or the ability of the agency to operate effectively, the agency must make effort to resolve the problem(s) presented, provide the patient with contact information for other agencies, or providers, who may be able to provide care; and document the efforts made to resolve the problem(s) into the clinical record. A plan shall be developed, or a referral made, for any continuing care indicated.” 1. The clinical record for Patient # 6 was reviewed on 5/9/22. The Plan of Care for the certification period dated 4/20/22 to 6/18/22 revealed a start of care date of 4/20/22. Plan of Care orders included skilled nursing (SN) three times per week for assessment, pain management, medication safety, nutrition, hydration, infection, surgical incision and wound care, including dressing and wound vacuum-assisted closure (VAC, a device used to help assist with wound healing) changes on Monday, Wednesday and Friday. Further review of the Plan of Care revealed no relevant patient diagnoses were included. The primary, surgical and other diagnoses sections of the Plan of Care were left blank. However, review of the comprehensive assessment completed by the agency registered nurse (RN) #6 on 4/20/22 revealed the patient had diagnoses that included a puncture wound to the abdomen, open wound, infection, pain, and post-surgical complications. a) The agency failed to ensure they made an effort to provide the patient with other agencies that may have been able to provide continued skilled nursing and wound management care prior to discharge from the agency after the problems presented by the patient's behavior related to the inappropriate text messages the patient sent to the agency SN prior to a scheduled SN visit. Review of the clinical summary in the Plan of Care completed by RN #6 on 4/21/22 revealed Patient #10 was admitted by the agency on 4/20/22 with a need for a SN to provide wound management after the patient had sustained a trauma to the abdominal area that resulted in postoperative complications. The clinical summary also noted the patient lived alone in a second story apartment, without additional support. Review of a communication log contained in Patient #10’s electronic health record (EHR) showed SN #7 had contacted licensed practical nurse (LPN) #3 to complain about the patient's inappropriate text messages she had received on 4/22/22, after she had contacted the patient to arrange a time for a scheduled SN visit. SN #7 further documented she was uncomfortable providing care for the patient as a result. Continued review of the communication log showed LPN #3 entered a communication note on 4/25/22 that noted Patient #10 was informed that the agency would no longer be able to provide wound care due to the patient being inappropriate with the clinician and was advised to contact his primary care provider for further instructions regarding care. Further record review revealed an agency staff member had obtained a verbal order from Patient #10’s physician of record on 4/22/22 at 2:15 p.m. to discharge Patient #10 from the agency due to being inappropriate with clinicians on multiple occasions. The verbal order was not signed by an agency clinician. Continued record review revealed no evidence the agency had contacted the patient to provide him with other agencies that may have been able to provide the continued skilled nursing and wound care management needs, prior to the abrupt discharge. During an interview on 5/10/22 at 3:00 p.m., with both the agency administrator and LPN #3 present, LPN #3 stated she had contacted Patient #10 and advised him he was being discharged from the agency, however she denied she had provided him with a list of other agencies to contact that may have been able to help him with his continued home health care needs. During the same interview on 5/10/22 at 3:00 p.m., the administrator stated it was agency policy to help connect patients with another agency that could provide care if a patient was being discharged for cause. The administrator acknowledged she was aware no one from the agency had contacted the patient to provide him with a list of other agencies to contact for continued care.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure a comprehensive assessment was completed during the last 5 days of the 60 day certification period for 2 of 6 patients admitted to the agency reviewed (Patients #7 and #8). 2. The clinical record for Patient #8 was reviewed on 5/9/22. The plan of care for the certification period dated 3/7/22 to 5/5/22, revealed a start of care date of 1/6/22; diagnoses included essential hypertension, encounter for fitting and adjustment of urinary device, and screening for other metabolic disorders. Plan of care orders included SN visits twice weekly for eight weeks for blood draws, medication management, and foley catheter management. a) The agency failed to conduct a recertification assessment for Patient #8 during the last five days of the 60 day certification period. Review of the clinical record revealed a verbal order from the physician on 4/14/22. The verbal order read SN visits should continue twice weekly for eight weeks for lab draws, foley catheter care, and medication teaching and setup. Further review of the clinical record revealed the agency completed a recertification assessment on 4/14/22, however the agency was not supposed to complete the recertification until 5 days before the end of the certification period or, between 5/1/22 and 5/5/22. The assessment completed on 4/14/22 was a recertification assessment. RN #6 reported Patient #8 would continue to receive weekly lab draws, medication management and foley management and education. RN #6 did not note any issues regarding the assessment, only the need to continue care. RN #6 did not report any change in condition for Patient #8. Review of the clinical record failed to reveal evidence that a recertification assessment had been conducted from 5/1/22 to 5/5/22 as required by regulation. During an interview on 5/10/22 at 11:10 a.m., the administrator stated she was not aware that the Patient #8 had not received a comprehensive assessment during the end of the certification period. The administrator stated she did not know why the RN completed the recertification assessment three weeks before it was due. The administrator confirmed Patient #8 was still receiving services from the agency and that a SN was providing services to the patient on 5/10/22. RN #6 who performed the assessment on 4/14/22 was no longer employed with the agency so was unable to answer the question as to why the assessment was done three weeks early. Findings include: 1. The clinical record for Patient #7 was reviewed on 5/9/22. The plan of care for the certification period dated 2/19/22 to 4/19/22, revealed a start of care date of 2/19/22; diagnoses included orthopedic aftercare following surgical amputation, type 2 diabetes with hyperglycemia and diabetic neuropathy, and hypertensive heart disease. Plan of care orders included physical therapy (PT) visits once a week for one week, three times weekly for two weeks, and twice weekly for four weeks for a home exercise program, patient/family education, and gait and balance training. a) The agency failed to conduct a recertification assessment for Patient #7 during the last five days of the 60 day certification period. Record review revealed PT #9 had documented an Outcome and Assessment Information Set (OASIS) assessment on 3/30/22 that noted Patient #7 was transferred to an inpatient facility and had been discharged from the home health agency. However, there was no further documentation as to why the patient had been admitted to the inpatient facility. Further record review showed registered nurse (RN) #6 had documented a verbal order from the patient's physician of record on 4/4/22 that noted a resumption of care was completed on 3/31/22 and that the physician had added Skilled Nurse (SN) visits, once per week for 6 weeks, for weekly lab draw and peripherally inserted central catheter (PICC) line care beginning 4/4/22 and occupational therapy (OT) was to evaluate and treat. The PT was also to evaluate and treat the patient. Continued record review failed to reveal evidence an RN or PT had conducted a resumption of care assessment. Record review revealed no evidence the agency had conducted a recertification assessment during the last five days of the certification period, 4/15/22 to 4/19/22. During an interview on 5/9/22 at 2:32 p.m., the administrator stated RN#6 had received the verbal order from Patient #7's physician to complete the resumption of care comprehensive assessment on 3/31/22. However, she stated RN #6 failed to complete the resumption of care comprehensive assessment. During an interview on 5/10/22 at 11:10 a.m., the administrator confirmed a resumption of care comprehensive assessment should have been completed for Patient #7 but she would need to ask her staff for further details as to why the resumption of care assessment was not completed. The administrator stated she believed that the resumption of care assessment (which was never completed), would suffice as a recertification assessment. During continued interview at 11:48 a.m., the administrator stated neither the resumption of care assessment nor the recertification assessment were ever completed. No further information or documentation was provided prior to survey exit on 5/10/22 at 3:45 p.m. as to why the agency failed to update and revise the patient’s comprehensive assessment. 2. The clinical record for Patient #8 was reviewed on 5/9/22. The plan of care for the certification period dated 3/7/22 to 5/5/22, revealed a start of care date of 1/6/22; diagnoses included essential hypertension, encounter for fitting and adjustment of urinary device, and screening for other metabolic disorders. Plan of care orders included SN visits twice weekly for eight weeks for blood draws, medication management, and foley catheter management. a) The agency failed to conduct a recertification assessment for Patient #8 during the last five days of the 60 day certification period. Review of the clinical record revealed a verbal order from the physician on 4/14/22. The verbal order read SN visits should continue twice weekly for eight weeks for lab draws, foley catheter care, and medication teaching and setup. Further review of the clinical record revealed the agency completed a recertification assessment on 4/14/22, however the agency was not supposed to complete the recertification until 5 days before the end of the certification period or, between 5/1/22 and 5/5/22. The assessment completed on 4/14/22 was a recertification assessment. RN #6 reported Patient #8 would continue to receive weekly lab draws, medication management and foley management and education. RN #6 did not note any issues regarding the assessment, only the need to continue care. RN #6 did not report any change in condition for Patient #8. Review of the clinical record failed to reveal evidence that a recertification assessment had been conducted from 5/1/22 to 5/5/22 as required by regulation. During an interview on 5/10/22 at 11:10 a.m., the administrator stated she was not aware that Patient #8 had not received a comprehensive assessment during the end of the certification period. The administrator stated she did not know why the RN completed the recertification assessment three weeks before it was due. The administrator confirmed Patient #8 was still receiving services from the agency and that a SN was providing services to the patient on 5/10/22. RN #6 who performed the assessment on 4/14/22 was no longer employed with the agency so was unable to answer the question as to why the assessment was done three weeks early.

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 nature of the standard level deficiency referenced to the condition, it was determined the Condition of Participation 484.60, CARE PLANNING, COORDINATION AND QUALITY OF CARE was out of compliance. This condition level deficiency was cited previously during a federal complaint survey on 4/14/22. A total of nine clinical records and four focus patient records were reviewed for compliance with the Condition and Standards for Care Planning, Coordination and Quality of Care. Specifically, Patient #1 was accepted for services to include skilled nursing needs, which included lab draws, surgical wound assessment, being provided with supplies to meet his clinical needs and coordination of care with the physician, however the agency failed to start services timely resulting in Patient #1 having an INR of 10.7 and having the potential for a negative outcome. These failures had the potential to affect all patients referred to and served by the home health agency. In addition to the failure identified in the patient example below the following standard level deficiencies were also cited. G580 Based on observation, interview and record review, the agency failed to ensure drugs, services and treatments were administered as ordered by a physician for 2 of 6 patients admitted to the agency reviewed. G602 Based on interview and record review, the agency failed to assure communication with all physicians involved in the plan of care for 2 of 7 who were accepted for services but not admitted to the agency. G608 Based on interview and record review, the agency failed to involve the patient, representative and caregiver in the coordination of care activities in order to meet the needs of the patient for 1 of 7 patients who were accepted for services but not admitted to the agency. Findings related to G 570 are as follows: Based on interview and record review the agency failed to ensure patients were accepted for treatment on the reasonable expectations the agency could meet the patient's medical needs in his place of residence for 1 of 7 who were accepted for services but not admitted to the agency (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 5/6/22. The agency never established a plan of care for Patient #1. Patient #1's referral to the agency from the hospital dated 4/26/22, revealed the patient was to receive skilled nurse (SN) visits for medication and disease management, postoperative incision assessment, and international normalized ratio (INR) lab draws. No orders for frequency of nursing visits were established. a) The agency failed to provide services to Patient #1 after assuming care and services upon acceptance of the referral from the hospital on 4/26/22. Review of the patient's referral to the agency dated 4/26/22, revealed Patient #1 had undergone heart surgery on 4/20/22 for a coronary artery bypass surgery as well as mitral valve replacement. After the surgery, Patient #1 began to take the following medication; warfarin (Coumadin) 5mg tablet take 1 tablet (5mg total) by mouth once a day at 4pm. Warfarin is a blood thinner that is used to prevent blood clots especially for patients who have had surgery for replacement heart valves or who have suffered a heart attack. Further review of Patient #1's referral, revealed the patient required INR lab draws. An INR lab draw is used to measure a patient's blood ability to clot. The point of the INR lab draw for Patient #1 was to make sure it would not be too low which could result in a blood clot forming in the blood vessels of Patient #1, or too high which would mean the blood would not clot and if the patient were to receive a wound or a cut the blood would not clot and the patient could potentially bleed out. During an interview on 5/9/22 at 10:31 a.m., the intake officer stated the agency had received the referral for Patient #1 on 4/26/22. The intake officer stated she informed the case manager for Patient #1 the agency would accept the patient to services on 4/26/22. The intake officer stated although she informed the case manager they would accept Patient #1 to services, the intake officer was unable to reach the patient to confirm insurance authorization. The patient was finally reached on 4/29/22, three days after the agency accepted the patient's referral. From 4/26/22 to 4/29/22 there was no documentation of the agency contacting the patient's physician regarding orders, or delaying the start of care for Patient #1 due to not being able to reach the patient. The agency failed to coordinate the care with the physician regarding the needs of the patient between 4/26/22 and 4/29/22 while the patient continued to take the warfarin medication, which could put Patient #1 in a dangerous situation of developing a blood clot or his blood not clotting. Review of the communication log for Patient #1 revealed, the agency was able to contact Patient #1 on 4/29/22 and informed him they would not be able to obtain the lab draw prescription due to a pending insurance authorization problem. Record review revealed another communication note to Patient #1's provider stating the agency would not be able to obtain a STAT (urgent) lab draw as the agency did not get insurance authorization. The agency then asked the provider to contact the patient for further instructions regarding this lab or to reschedule the lab draws for Monday. Both of these communication logs were entered into the agency's electronic medical record (EMR) system by licensed practical nurse (LPN) #3. There was no evidence to show who the LPN had spoken with or what the plan was to ensure Patient #1 received the required services inclusive of INR lab draw. During an interview on 5/9/22 at 10:30 a.m., LPN #3 stated Patient #1 was initially accepted for services, however they eventually had to decline the patient. She stated she assumed Patient #1 had a Peripherally Inserted Central Catheter (PICC) line, and that was how the lab draws would be completed, however Patient #1 did not have a PICC line. LPN #3 stated the agency did not have the butterfly needles to do a lab draw and therefore would not be able to complete the blood draw regardless of issues regarding insurance authorization. The agency failed to have the necessary supplies to meet the patients needs before accepting the patient for treatment, creating a potentially dangerous situation for Patient #1. Record review revealed a home health care new referral/prior authorization form dated 4/29/22. The form revealed Patient #1 was accepted for services by the agency, although the agency had previously accepted the patient for services on 4/26/22. The form also revealed that the start of care date for the patient was to be 5/1/22. Further review of the clinical record for Patient #1 revealed, he was never assessed to start services on 5/1/22 or at any day following. Further review of the clinical record also revealed the agency never contacted the physician of Patient #1 for a delay in the start of care orders until 5/3/22, a period of seven days from the original referral. During an interview on 5/9/22 at 10:30 a.m., LPN #3 stated she had contacted the physician for Patient #1 and had spoken to them about changing the start of care date to 5/3/22. Review of the clinical record failed to reveal any delay in the start of care order from the physician to the agency. The agency failed to meet the medical needs of the patient by not starting services within 48 hours of accepting the referral, coordinating care with the physician, coordinating with the referral source regarding their inability to provide the required care and/or ensuring Patient #1 was referred to another agency in order to obtain the INR lab draw that was ordered. Review of hospital documents dated 5/3/22 revealed Patient #1 had gone to a private company to receive a lab draw. The lab draw came back with an INR level of 10.7. (An INR level of 10.7 presents a severe risk in blood clotting time.) In summary, Patient #1 was referred and accepted for services by the agency on 4/26/22. Services were to be started by 4/28/22 and INR labs were to be drawn by the agency so the results could be monitored by the physician. The start of care assessment and INR lab were never completed by the agency and there was no evidence the agency had coordinated with the physician or referral source regarding their inability to provide the INR lab until 4/29/22, one day after the start of care and INR were to be performed. The agency continued to hold the referral awaiting insurance authorization and received a second referral on 4/29/22 to start services on 5/1/22. The agency failed to complete the start of care and INR lab by 5/1/22 and had no documentation to show they had coordinated Patient #1's care with the physician or referral source. Subsequently, on 5/3/22, Patient #1 had an INR lab drawn at the hospital. The results of Patient #1's INR lab was a 10.7, placing Patient #1 in a dangerous situation of potentially bleeding out for a period of seven days. The agency accepted the referral of Patient #1 without having the proper supplies for an INR lab draw; failed to properly coordinate care with the patient, his physician and the referral source; and failed to properly coordinate a start of care date with the patient and the physician. These failures created the situation of Patient #1 needing to be seen in the emergency department and receive emergency treatment for care he should have received the previous week. 2. During an interview on 5/10/22 at 1:01 p.m., the administrator stated the agency should have completed a start of care assessment for Patient #1 regardless if the agency had the necessary supplies to perform the lab draw. The administrator stated the agency also failed to coordinate the care with the physician since the agency did not receive orders for a start of care delay, nor is there documentation the agency informed the physician the agency would not be able to get a lab draw due to a lack of supplies. The administrator stated the agency should have had Patient #1 go and have a lab draw at an outside company, or at a hospital.

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 observation, interview and record review, the agency failed to ensure drugs, services and treatments were administered as ordered by a physician for 2 of 6 patients admitted to the agency reviewed (#6 and #8). This deficiency was cited previously during a federal complaint survey 4/14/22. 2. The clinical record for Patient #8 was reviewed on 5/9/22. The plan of care for the certification period dated 3/7/22 to 5/5/22, revealed a start of care date of 1/6/22; diagnoses included essential hypertension, encounter for fitting and adjustment of urinary device, and screening for other metabolic disorders. Plan of care orders included SN visits twice weekly for eight weeks for blood draws, medication management, and foley catheter management. a) The agency failed to ensure a SN provided catheter care only as ordered by the physician. Review of the physician orders dated 4/15/22 revealed orders for foley catheter management and education. The physician order did not include specific instructions regarding the size of foley catheter to use, the amount of liquid to use for irrigation or what the liquid was to be used, and no information regarding the size of the bulb. Review of the SN visit dated 4/28/22 revealed RN #8 changed the foley catheter for Patient #8. RN #8 documented she used a 14 french foley catheter, irrigated it with 10 milliliters (mL), and inflated the bulb to 10 mL. There was no evidence the agency had obtained orders to use the 14 french foley catheter, how to irrigate the catheter, or how far to inflate the bulb. During interview on 5/10/22 at 10:30 a.m., the administrator stated the agency did not have specific orders regarding the catheter care for Patient #8. The administrator stated the only orders the agency had was orders for foley catheter management and education, but the agency had no orders regarding the size of the catheter to use or irrigation orders for the catheter or the size of the bulb. Findings included: AGENCY POLICY: According to the agency policy titled “Care follows the Plan of Care”, (undated, in pertinent parts), “Care follows a written plan of care established by and periodically reviewed, by a doctor of medicine, osteopathy or podiatric medicine. Each patient must receive an individualized written plan of care, including any revisions or additions. It is the responsibility of the agency that there is evidence in the patient record that the plan of care conforms to physician orders and that drugs, services and treatments are administered, only, as ordered by the physician.” 1. The clinical record for Patient # 6 was reviewed on 5/9/22. The Plan of Care for the certification period dated 4/26/22 to 6/24/22 revealed a start of care date of 4/26/22. Diagnoses included malignant neoplasm of the colon, liver, peritoneum and intestinal blockage. Plan of Care orders included skilled nursing (SN) visits once per week for assessment, PICC (peripherally inserted central catheter) line care, lab draws, and the assessment of the patient's ability to infuse TPN (total parenteral nutrition) three times a week through the PICC line. The Plan of Care included: the following medications: Robaxin, 500mg (milligrams) three times daily as needed, Xarelto, 20mg daily, Oxycodone, 30mg three to four times daily, Fentanyl transdermal patch, to be changed every three days, and, TPN (total parenteral nutrition) three times per week to be infused through the PICC line. a) The agency failed to ensure the SN provided medication through the PICC line only as ordered by the physician. During a home visit observation on 5/10/22 at 12:00 p.m., registered nurse (RN) #5 was observed withdrawing blood from Patient #6’s PICC line and pushing three separate syringes with a clear liquid into the PICC line. When asked for an explanation of the procedure, RN #5 stated she was collecting blood for lab work as ordered by the physician by withdrawing the blood from the PICC line then followed the blood withdrawal by pushing 10 milliliters of normal saline into the PICC line to flush the line clean and finishing with 5 milliliters of Heparin which was used to prevent the PICC line from clotting and becoming non-functional. The RN stated she followed the same procedure every week when she would collect blood for weekly lab work. Review of SN visit notes completed by RN #5 on 4/27/22 and 5/3/22 revealed the RN had documented the same procedure of withdrawing blood for lab work followed by the insertion of the normal saline and heparin medications into Patient #6’s PICC line. Clinical record review failed to show the physician had ordered the normal saline or heparin medications. During interview with RN #5 on 5/10/22 around 12:45 p.m., RN #5 stated the medications were provided by the infusion pharmacy and that they supplied the normal saline and heparin medications for use when the PICC line had been utilized. RN #5 reviewed the Plan of Care and acknowledged the medications had not been ordered by the physician. RN #5 stated she would contact Patient #6’s physician of record and obtain the appropriate medication orders.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to assure communication with all physicians involved in the plan of care for 2 of 7 who were accepted for services but not admitted to the agency (Patients #1 and #12). The deficiency was cited previously during a federal complaint survey 4/14/22. 2. The Clinical record for Patient #12 was reviewed on 5/10/22. The agency never established a plan of care for Patient #12. Patient's #12's diagnoses included forefoot amputation to the left foot. According to the referral, dated 4/13/22, Patient #12 was to receive SN services twice a week for wound care and treatment and physical therapy (PT) evaluation and treatment. a) The agency failed to communicate with the physician regarding the patients whereabouts and the agency's inability to provide care to Patient #12. Review of Patient #12's referral dated 4/13/22 revealed the agency was to provide wound care services twice a week and provide a PT evaluation. Review of the clinical record revealed a communication log, dated 4/14/22, in which the agency accepted Patient #12 to service on 4/14/22. Further review of the clinical record failed to reveal a start of care assessment on 4/16/22 or within 48 hours of the agency accepting Patient #12 to services and there was no evidence the agency had contacted the physician about the inability to locate Patient #12 in order to start services. Review of the clinical record for Patient #12 revealed the following communication notes: -On 4/14/22 the intake officer called the physician for Patient #12 to verify they were the physician for Patient #12; -On 4/18/22 the intake officer spoke to Patient #12's family, who informed the agency Patient #12 was still on the streets, and another phone call to the homeless shelter were Patient #12 was to be staying after his foot surgery. The call to the homeless shelter revealed Patient #12 had never checked in to the homeless shelter and was nowhere to be found. Review of the clinical record failed to reveal the agency made any attempts to contact Patient #12 between 4/14/22 and 4/18/22. The agency did not contact family members of Patient #12 or the homeless shelter until 4/18/22, two days after Patient #12 was to receive his start of care comprehensive assessment. Review of the clinical record failed to reveal the agency had communicated with the physician after 4/14/22 in regards to a delay for the start of care orders, or the agency's inability to locate or treat Patient #12. During an interview on 5/10/22 at 10:54 a.m., the administrator and intake officer stated the agency had not reached out the to the physician regarding the agency's inability to locate Patient #12, the agency not having been able to provide the twice weekly wound care for the patient, and that the agency would not be able to have a physical therapist evaluate the patient. The administrator and intake officer stated the case manager of Patient #12 was contacted but they did not contact the physician. Findings include: 1. The clinical record for Patient #1 was reviewed on 5/6/22. A plan of care for Patient #1 was never established by the agency. Patient #1's hospital referral to the agency dated 4/26/22, revealed Patient #1 was to receive skilled nursing (SN) visits for medication and disease management, postoperative incision assessment, and international normalized ratio (INR) lab draws. No orders for the frequency of nursing visits were established. a) The agency failed to ensure communication with Patient #1's physician regarding the patient's specific nursing needs. Specifically the agency failed to communicate and coordinate care with the patient's physician, following the failure to complete the referred SN task of patient #1's initial assessment and INR draw as written into the referral order received and accepted by the agency on 4/26/22. Review of the patient's referral to the agency, dated 4/26/22, revealed Patient #1 had undergone heart surgery on 4/20/22 for a coronary artery bypass surgery as well as mitral valve replacement. After the surgery Patient #1 began to take the following medication; warfarin (Coumadin) 5mg tablet, 1 tablet (5mg total) by mouth once a day at 4:00 p.m. Further review showed the agency received and accepted Patient #1's referral on 4/26/22. The referral requested INR lab draws to be completed by the agency, so the results of the draw could be monitored by the patient's physician. During an interview on 5/9/22 at 10:31 a.m., licensed practical nurse (LPN) #3 was asked if the agency had ever admitted a patient they were unable to provide the care prescribed in the referral. LPN #3 stated yes, they had received the referral for Patient #1 on 4/26/22, however eventually declined to provide services to Patient #1. LPN #3 stated when the patient was accepted, she assumed the patient had a Peripherally Inserted Central Catheter (PICC) line to draw from. LPN #3 stated when she realized the patient did not have a PICC line, she tried to find the supplies (butterfly needles) to complete the blood draw, however supplies were not available. LPN #3 further stated, following the missed blood draw task, she called the case manager to advise of her inability to complete the blood draw. When inquired if LPN #3 reached out to the physician to advise and further coordinate the patient's care, LPN #3 replied she did and that there should be a delay order in the patient's record, however there was no evidence of an order to delay services or communication with the physician regarding Patient #1's INR lab. Following the interview the first request was made for the delay order from Patient #1's physician. Supplemental requests for documentation of the physician's verbal order to delay the INR draw were made to the administrator on; 5/9/22 at 10:52 a.m., 5/9/22 at 2:00 p.m., and 5/10/22 p.m. No delay of order for Patient #1 was produced for review from the agency by the conclusion of the investigation on 5/10/22. Review of the communication log for Patient #1 revealed the agency was able to contact Patient #1 on 4/29/22 and informed him they would not be able to obtain the lab draw prescription due to a pending insurance authorization problem. Record review revealed another communication note to Patient #1's provider stating the agency would not be able to obtain a STAT (urgent) lab draw as the agency did not get insurance authorization. The agency then asked the provider to contact the patient for further instructions regarding this lab or to reschedule the lab draws for Monday. However, there was no evidence the agency had coordinated their failure to start services and provide Patient #1 with an INR lab on 4/28/22 with the physician. Both of these communication logs were entered into the agency's electronic medical record (EMR) system by LPN #3. Record review revealed a home health care new referral/prior authorization form dated 4/29/22. The form revealed Patient #1 was accepted for services by the agency, although the agency had previously accepted the patient for services on 4/26/22. The form also revealed that the start of care date for the patient was to be 5/1/22. Further review of the clinical record for Patient #1 revealed, he was never assessed to start services on 5/1/22 or at any day following. Further review of the clinical record also revealed the agency never contacted the physician of Patient #1 for a delay in the start of care orders until 5/3/22, a period of seven days from the original referral. During an interview on 5/9/22 at 10:30 a.m., LPN #3 stated she had contacted the physician for Patient #1 and had spoken to them about changing the start of care date to 5/3/22. Review of the clinical record failed to reveal any delay in the start of care order from the physician to the agency. The agency failed to meet the medical needs of the patient by not coordinating care with the physician. Review of hospital documents dated 5/3/22 revealed Patient #1 had gone to a private company to receive a lab draw. The lab draw came back with an INR level of 10.7. (An INR level of 10.7 presents a severe risk in blood clotting time.) In summary, Patient #1 was referred and accepted for services by the agency on 4/26/22 to complete a start of care assessment by 4/28/22 and the referral also showed the agency was to complete INR lab draws for physician monitoring. The start of care assessment and INR lab were never completed by the agency and there was no evidence the agency had coordinated with the physician or referral source regarding their inability to provide the INR lab until 4/29/22, one day after the start of care and INR were to be performed. The agency continued to hold the referral awaiting insurance authorization and received a second referral on 4/29/22 to start services on 5/1/22. The agency failed to complete the start of care and INR lab by 5/1/22 and had no documentation to show they had coordinated Patient #1's care with the physician or referral source. Subsequently, on 5/3/22, Patient #1 had an INR lab drawn at the hospital. The results of Patient #1's INR lab was a 10.7, placing Patient #1 in a dangerous situation of potentially bleeding out for a period of seven days.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to involve the patient, representative and caregiver in the coordination of care activities in order to meet the needs of the patient for 1 of 7 patients who were accepted for services but not admitted to the agency (Patient #1). This deficiency was cited previously during a federal complaint survey 4/14/22. Findings include: 1.The clinical record for Patient #1 was reviewed on 5/6/22. The agency never established a plan of care for Patient #1. Patient #1's referral to the agency from the hospital dated 4/26/22, revealed the patient was to receive skilled nurse (SN) visits for medication and disease management, postoperative incision assessment, and international normalized ratio (INR) lab draws. No orders for frequency of nursing visits were established. a) The agency failed to coordinate care with Patient #1. Specifically, Patient #1 required an INR lab draw following his hospitalization and referral to the agency, however there was no evidence to show the agency had made attempts to contact the patient prior to 4/29/22 and convey the urgency of the INR lab. Review of the patient's referral to the agency, dated 4/26/22, revealed Patient #1 had undergone heart surgery on 4/20/22 for a coronary artery bypass surgery as well as mitral valve replacement. After the surgery Patient #1 began to take the following medication; warfarin (Coumadin) 5mg tablet, 1 tablet (5mg total) by mouth once a day at 4:00 p.m. Further review showed the agency received and accepted Patient #1's referral on 4/26/22.Due to the agency accepting Patient #1's referral on 4/26/22, services were to be started by 4/28/22 and INR labs were to be drawn by the agency so the results could be monitored by the physician. Review of the clinical record for Patient #1 revealed a communication note dated 4/29/22. The note explained the agency told Patient #1 they would not be able to do a lab draw today due to insurance pending authorization. There was no evidence the agency explained to Patient #1 the importance of having a lab draw due to the possible hazardous position the patient could be in with a low or high INR value. Furthermore, there was no evidence the agency had contacted the patient prior to 4/29/22 regarding their inability to start services and complete the INR lab as ordered. Further record review showed no evidence the agency had contacted Patient #12 or family regarding their inability to provide services and Patient #12's urgent need for an INR. During an interview on 5/9/22 at 10:30 a.m., licensed practical nurse (LPN) #3 stated the INR lab had to be drawn in a timely manner. LPN #3 stated the day the agency received the referral they were supposed to go out the next day to do the lab draw for Patient #1. LPN #3 stated she had told the physician of Patient #1 to refer him to an outside lab draw company, however she did not state if she informed Patient #1 about the need to receive a lab draw from an outside private company or from a hospital. During an interview on 5/10/22 at 1:01 p.m., the administrator stated they should have done everything possible for Patient #1, and even paid for a taxi to drive the patient to a site where the patient could have received a lab draw. The administrator went on to state the agency was responsible for patients and if the agency could not provide services then it was up to the agency to find an alternative.

A complaint survey prompted by #CO62322 was completed on 4/14/22. A condition level deficiency was cited. 484.60 Care Planning, Care Coordination and Quality of Care. Additionally, six standard level 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 6 of 10 patients reviewed (Patient #2, #3, #4, #5, #6 and #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 4/12/22. Review of the plan of care for the certification period 12/14/21 to 2/11/22 revealed a start of care of 12/14/21; diagnoses included Ischemic cardiomyopathy exacerbation, atherosclerotic heart disease (ASHD), other specific depressive episodes, type 2 diabetes mellitus without complications, and contusion of the right knee. Plan of care orders included; skilled nursing (SN) once weekly on Wednesday to assess and evaluate wound V.A.C. (vacuum assisted closure) dressing change, physical therapy (PT) had no duration or frequency listed, to assess, evaluate and treat, and occupational therapy (OT) had no duration or frequency listed, to assess, evaluate and treat. a) The agency failed to ensure Patient #7's comprehensive assessment had been updated and revised to accurately reflect the patient's current health status, specifically for transfer to another service area and discharge. Review of the OASIS Assessment Details dated 12/14/21, completed by RN #4, showed the RN identified Patient #7 had a need for a wound V.A.C. and planned to go weekly on Wednesday for wound care and assessments. Further review showed the need for skilled PT and OT to evaluate and treat. Review of the Home Health plan of care and certification dated 12/14/21 for the certification period of 12/14/21 to 2/11/22, showed SN frequency and duration of weekly on Wednesday for wound V.A.C. care and wound assessment, as well as for skilled Pt and OT to assess, evaluate and treat. Review of the clinical record revealed SN completed 2 visits on 12/14/21 and 12/22/21. Review of the clinical record revealed skilled OT completed 2 visits on 12/16/21 and 12/23/21. Review of the clinical record revealed skilled PT completed 2 visits on 1/6/22 and 1/11/22. Review of the clinical record failed to reveal evidence of an updated comprehensive assessment, discharge summary or transfer summary to show completion of care for Patient #7. During an interview 4/12/22 at 8:48 a.m., OT # 5 stated, she did not recall the case and had nothing to add. During an interview on 4/12/22 at 12:57 p.m., registered nurse (RN) #4, stated she had multiple communications with the physician and Patient #7's wife and that he had been admitted to the hospital, however record review failed to reveal any documentation Patient #7 had moved to a facility. During an interview on 4/12/22 at 12:34 p.m., PT # 3 stated he was not working for the agency in December and was not sure why he first saw Patient #7 on 1/6/22. He further stated he was no longer seeing him because he wanted to go back to work. During an interview on 4/13/22 at 2:07 p.m., RN #4 stated, she usually called the wife the day before a visit to schedule it but when she called in December she found out Patient #7 was in the hospital and was going to a rehabilitation facility after that. 2. The clinical record for Patient #5 was reviewed on 4/11/22. Review of the plan of care for the certification period of 2/11/22 to 4/11/22 revealed a start of care date of 2/11/22; diagnoses included; fracture of neck, fusion of spine and failure to thrive. Plan of care orders included; SN daily to provide wound care, home health aide (HHA) with no frequency or duration to provide assistance with personal care and assistance with activities of daily living (ADLs), medical social worker (MSW) with no frequency or duration to evaluate the living situation and provide a support system, PT one time a week for five weeks, to establish, upgrade, teach and provide education, therapeutic exercises, gait and transfer training, muscle re-education, and energy conservation; and OT one time a week for six weeks, to evaluate, establish, upgrade, teach and provide a home exercise program, independent living skills, training of equipment and therapeutic exercises. a) The agency failed to ensure Patient #5's comprehensive assessment had been updated and revised to accurately reflect the patient's current health status, specifically for recertification and/or discharge. Review of the Home Health plan of care and certification dated 2/11/22 for the certification period of 2/11/21 to 4/11/22, signed by the physician 3/1/22, showed SN frequency and duration of daily, PT once a week for five weeks and OT once a week for six weeks. Review of the clinical record revealed the SN completed 2 visits on 2/11/22 and 2/20/22. Review of the clinical record revealed that RN #2 discontinued services on 2/24/22 due to the wound being healed. Review of the clinical record revealed skilled OT completed 3 visits on 2/18/22, 2/24/22, and 3/3/22, however it failed to reveal any discontinuation of services. Review of the clinical record revealed skilled PT completed 6 visits on 2/17/22, 2/25/22, 3/4/22, 3/11/22, 3/18/22 and 3/29/22, however it failed to reveal discontinuation of services or recertification. Review of the clinical record failed to reveal evidence of an updated comprehensive assessment, or discharge summary to show continuation or completion of care for Patient #5. During an interview on 4/11/22 at 2:55 p.m., RN #2 stated she was not able to see Patient #5 daily because he lived in a shelter and she was not able to locate him. During an interview on 4/11/22 at 1:53 p.m., Employee #6 stated that he was no longer seeing because he was unable to locate Patient #5. During an interview on 4/12/22 at 8:48 a.m., OT #5, stated that she had documented her discontinuation of services, however when asked, she was not able to provide the note. During an interview on 4/13/22 at 10:33 a.m., a representative from the physician's office stated they had the verbal order from SN to discontinue services but nothing further. 3. The clinical record for Patient #6 was reviewed on 4/12/22. Review of the plan of care for the certification period of 1/31//22 to 3/31/22 revealed a start of care date of 1/31/22; diagnoses included acute postprocedural pain, intervertebral disc displacement, lumbar region, type 2 diabetes mellitus without complications and essential hypertension. Plan of care orders included PT two times per week for four weeks to establish and teach home exercise program, therapeutic exercise, transfer, gait and balance training and to teach fall safety and body mechanic precautions. a) The agency failed to ensure Patient #6's comprehensive assessment had been updated and revised to accurately reflect the patient's current health status, specifically for recertification. Review of the OASIS Assessment Details dated 1/31/22, completed by PT #3 revealed Patient #6 had a need for skilled PT services twice a week for four weeks. Review of the home health plan of care and certification dated 1/31/22 for certification period 1/31/22 to 3/31/22 revealed an order for skilled PT services twice a week for four weeks. Review of the clinical record revealed 12 skilled PT visits were completed on 1/31/22, 2/23/22, 2/25/22, 3/3/22, 3/8/22, 3/10/22, 3/15/22, 3/24/22. 3/28/22, 3/29/22, 4/4/22, 4/6/22 and 4/11/22. Review of the clinical record failed to reveal an updated comprehensive assessment for a second benefit period which should have started on 4/1/22. During an interview on 4/12/22 at 12:30 p.m., PT #3 stated he did not do a recertification OASIS for Patient #6. During an interview 4/13/22 at 4:14 p.m., the director of nursing (DON) stated there were multiple locations within the electronic medical record that notify a clinician of when a recertification is due. During an interview 4/14/22 at 7:30 a.m., Patient #6's daughter stated they had some issues with receiving authorization from the insurance company but her mother was still on service receiving PT. 4. Similar findings of failing to ensure a comprehensive assessment that accurately reflected the patient's current health status had been updated was found for Patients #2, #3 and #4. Specifically, record review revealed no evidence Patient #2 received a discharge assessment for SN, PT or OT; Patient #3 revealed no discharge assessment for PT; Patient #4 revealed no discharge assessment for PT or OT.

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 AND QUALITY OF CARE was out of compliance. A total of 10 clinical records were reviewed for compliance with the Condition and Standards Care Planning, Coordination and Quality of Care. Record review revealed a pattern of failures in regard to the home health agency ensuring care and services provided met the patient's needs. Review revealed the agency had provided care without a physician's order, conformed with physician orders received, coordinated services with physicians, and involved patients and care teams in care delivery to ensure the patient needs were met. These failures had the potential to affect all patients served by the home health agency. G580- Based on interview and record review, the agency failed to provide services and treatments only as ordered by the physician for 6 of 10 patients reviewed who received physical, occupational and skilled nursing services. G576- Based on interview and record review, the agency failed to record all patient care orders in the plans of care for 1 of 1 patients with a wound vacuum assisted closure. G578- Based on interview and record review, the agency failed to ensure services were provided in accordance with physician's orders for 3 of 10 records reviewed. G602- Based on interview and record review, the agency failed to ensure communication with all physicians involved in the plan of care in 7 of 10 patient records reviewed. G608- Based on interview and record review, the agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers as appropriate in 7 of 10 patient records reviewed.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to record all patient care orders in the plans of care for 1 of 1 patient with a Wound V.A.C. (vacuum assisted closure of a wound). (Patient #7) Findings include: 1. The clinical record for Patient #7 was reviewed on 4/12/22. Review of the plan of care for the certification period 12/14/21 to 2/11/22 revealed a start of care of 12/14/21; diagnoses included Ischemic cardiomyopathy exacerbation, atherosclerotic heart disease (ASHD), other specific depressive episodes, type 2 diabetes mellitus without complications, and contusion of the right knee. Plan of care orders included; skilled nursing (SN) once weekly on Wednesday to assess and evaluate wound V.A.C. dressing change, physical therapy (PT) had no duration or frequency listed, to assess, evaluate and treat and occupational therapy (OT) had no duration or frequency listed, to assess, evaluate and treat. a) The agency failed to ensure all patient care orders were included in the plan of care, specifically orders for a wound V.A.C. and dressing changes. Review of Patient #7's plan of care dated 12/14/21 to 2/11/21 revealed SN to assess and evaluate wound V.A.C. dressing changes; however, the plan of care failed to have specific orders for wound care, dressing changes or wound V.A.C. settings. Review of registered nurse (RN) #4's OASIS assessment details dated 12/14/21, revealed patient #7 had a surgical wound to his right knee and the physician had ordered wound care as follows: negative wound pressure therapy 125mmHg, dressing change once weekly on Wednesday and as needed (PRN). Review of RN #4's nurses note dated 12/22/21 revealed the RN performed wound care to the right knee as follows; old dressing removed, using aseptic technique, SN cleansed the wound with normal saline (NS) solution, dried with gauze, prepared skin peri-wound with skin prep, filled the cavity with black foam, covered and secured with drape, and applied tubing. RN #4 then applied negative pressure device at 125mmHg, continuously. Clinical record review failed to reveal evidence of physician orders for the wound V.A.C.; which should include how to clean the wound and periwound (area around the actual wound), the type of foam to use, the type of dressing to cover the wound with, and the settings for the wound V.A.C. During an interview 4/12/22 at 12:57 p.m., RN #4 verified she saw Patient #7 two times to provide wound care including dressing changes for the wound V.A.C. RN #4 further stated she was unaware the order for wound care on a plan of care needed to be specific, she thought that because it had the 125mmHg the order was complete.

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 1 of 1 patients reviewed with a physician approved plan of care. (Patient #5) Findings include: 1. The clinical record for Patient #5 was reviewed on 4/11/22. Review of the plan of care for the certification period of 2/11/22 to 4/11/22 revealed a start of care date of 2/11/22; diagnoses included; fracture of neck, fusion of spine and failure to thrive. Plan of care orders included; skilled nursing (SN) daily to provide wound care, home health aide (HHA) with no frequency or duration to provide assistance with personal care and assistance with activities of daily living (ADLs), medical social worker (MSW) with no frequency or duration to evaluate the living situation and provide a support system, physical therapy (PT) one time a week for five weeks, to establish, upgrade, teach and provide education, therapeutic exercises, gait and transfer training, muscle re-education, and energy conservation; and occupational therapy (OT) one time a week for six weeks, to evaluate, establish, upgrade, teach and provide a home exercise program, independent living skills, training of equipment and therapeutic exercises. a) The SN failed to complete daily wound care and wound assessment as ordered. Review of the clinical record revealed a face to face visit, signed and dated by the physician on 2/18/22, indicating the need for nursing and therapy services. Review of the physician-signed home health plan of care and certification form dated 2/11/22 for the certification period of 2/11/22 to 4/11/22, revealed a frequency and duration of daily skilled nursing visits. Review of the clinical record for Patient #5, revealed RN #2 saw Patient #5 two times, once for the start of care on 2/11/22 and then again on 2/20/22 when she discharged him from SN services, due to the wound being granulated. Record review failed to reveal daily SN visits for Patient #5, as ordered from 2/11/22 to 4/11/22. During an interview on 4/11/22 at 2:55 p.m., RN #2 stated she was not able to see Patient #5 daily because he lived in a homeless shelter and she could not find him. She further stated she did not document the attempted visits. b) The agency failed to ensure OT visits were completed as ordered. Review of the clinical record revealed a face to face visit, signed and dated by the physician on 2/18/22, indicating the need for nursing and therapy services. Review of the insurance authorization dated 3/15/22 indicated authorization for two OT visits. Review of the physician-signed home health plan of care and certification form dated 2/11/22 for the certification period of 2/11/22 to 4/11/22, revealed skilled OT orders for once a week for six weeks. Review of the clinical record for Patient #5 revealed the OT did an evaluation on 2/18/22, then subsequent visits on 2/24/22 and 3/3/22 for a total of three visits. The occupational therapy note dated 3/3/22 completed by OT #5, indicated Patient #7 was progressing towards goals and had not met his goals as of that date. The clinical record failed to reveal any further OT visit notes or documentation as to why OT #5 stopped seeing Patient #5. During an interview on 4/12/22 at 8:48 a.m. OT #5 stated patient #5 was being seen by SN and PT often as well as going to the clinic. She stated it was hard for her to make her visits and thought she documented her discontinuation of services. OT #5 further stated that if there was nothing in the medical record, it may have been through a tiger text (a system used for communication that is not recorded in patients' medical records), she was not able to provide proof of the communication. During an interview on 4/12/22 at 10:35 a.m., RN #2 stated she was not able to find any documentation as to why OT only completed two visits and did not meet frequency. During an interview on 4/13/22 at 10:49 a.m., a representative from Patient #5's physician office, stated she could not see any communication from OT #5 in regards to services being provided or having stopped. c) The agency failed to ensure PT visits were completed as ordered. Review of the clinical record revealed a face to face visit, signed and dated by the physician on 2/18/22, indicating the need for nursing and therapy services Review of the insurance authorization dated 3/15/22 indicated authorization for four PT visits. Review of the plan of care dated 3/4/22 revealed orders for PT to assess, evaluate and treat, as well as services to be provided once the first week then two times a week for three weeks. Review of the clinical record revealed PT visits were made on 3/4/22 for the start of care and subsequent visits on 3/9/22 and 3/11/22. However, the clinical record failed to reveal any further visits or evidence of discontinuation of services for PT. During an interview on 4/13/22 at 2:15 p.m., the director of nursing (DON) stated she could not find any documentation to support if PT was still seeing Patient #8 or not. d) The agency failed to ensure a MSW provided support or help with Patient #5's living situation. Review of the physician-signed home health plan of care and certification form dated 2/11/22 for the certification period of 2/11/22 to 4/11/22, revealed a frequency and duration for the MSW to evaluate the living situation, and support system. Record review completed on 4/11/22, failed to reveal any MSW notes or visits. During an interview on 4/11/22 at 2:41 p.m., the administrator stated she had tried to contract for a MSW but was not able to find one. The administrator also verified the order for the MSW should have been discontinued and communicated with the physician. e) The agency failed to ensure HHA services were provided. Review of the physician-signed home health plan of care and certification form dated 2/11/22 for the certification period of 2/11/22 to 4/11/22, revealed a frequency and duration for the HHA to provide assistance with personal care and assistance with ADLs. Review of the clinical record on 4/11/22, failed to reveal any HHA services being provided. During an interview on 4/11/22 at 9:50 a.m., the administrator stated they did not have any HHA on staff and were not providing HHA services.

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 provide services and treatments only as ordered by the physician for 6 of 10 patients reviewed (Patients #2, #3, #4, #6, #7 and #8). Findings include: 1. The clinical record for Patient #2 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/7/22 to 4/7/22 revealed a start of care date (SOC) of 2/7/22; diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hypoxemia, thrombocytopenia and bipolar disorder. Plan of care orders included; physical therapy (PT) one time a week for one week, two times a week for three weeks to establish and teach home exercise program, evaluation, therapeutic exercise, gait training, functional mobility training and to teach fall safety; occupational therapy (OT) one time a week for one week, two times a week for three weeks to provide evaluation, establish home exercise program, independent living training, teach activities of daily living skills, therapeutic exercise and energy conservation techniques; and skilled nursing (SN) one time a week for four weeks for evaluation, medication and symptom management. a) The agency failed to obtain physician's orders for medication, COPD and congestive heart failure (CHF) management, by the SN. Review of the clinical record failed to show an order had been obtained by the agency to provide care. Review of the clinical record revealed a referral from Denver Health Hospital Authority, dated 2/2/22, and signed by the physician, requesting home health services for SN, PT, and OT. Review of the clinical record revealed a home health plan of care and certification dated 2/7/22, for the certification period dated 2/7/22 to 4/7/22, and not signed by the physician, by the end of the certification period, indicated the need for SN once a week for four weeks. Further review of the clinical record revealed evidence of documented SN visit notes indicting that the SN saw Patient #2 on 2/7/22 and again on 2/17/22 when Patient #2 was discharged from nursing services. Review of a document titled Verbal Order showed on 2/22/22 at 22:36 p.m., RN #10 had requested a physician order. The document which was not signed by the physician, indicated RN #10 spoke with a physician's representative for the order. Furthermore the document was indicated as a late entry for 2/17/22 to discontinue nursing services due to goals having been met. RN #10 was not available for interview as she was no longer with the agency During an interview on 4/12/22 at 2:14 p.m., the administrator confirmed RN #10 was no longer with the agency, and stated she was not aware of why the services were discontinued as no communication about the case was discussed with her. b) The agency failed to obtain physician's orders for PT services. Review of the request for authorization from Denver health dated 2/19/22, not signed by a physician, indicated approval for seven PT visits from 2/7/22 to 4/7/22. Review of the home health certification and plan of care, with start of care date 2/7/22 for the certification period of 2/7/22 to 4/7/22, not signed by a clinician or the physician, indicated a PT frequency of one time for one week, then two times a week for three weeks. There were no indications if the plan of care had been discussed with or ordered by the physician. Further review of the clinical record revealed a requested order, completed by PT #12 for PT change of condition frequency to one time a week for one week, then two times a week for three weeks, dated 3/4/22 at 16:30 p.m. This request was made after seven visits had been made to Patient # 2. The request was not signed by the physician. Clinical record review revealed Patient #2 was seen by various PT's on 2/7/22, 2/10/22, 2/17/22, 2/18/22, 2/22/22, 2/24/22, 3/4/22, 3/10/22, and 3/15/22. Of these visits only the visit done on 2/7/22 was approved by the physician. During an interview on 4/12/22 at 8:43 a.m., PT #12 stated she usually obtained the verbal order for care, then would let the office know so they could follow up on the order. During an interview on 4/12/22 at 2:14 p.m., the administrator stated that after documents were sent to the physician, no one tracked them to make sure they came back signed. c) The agency failed to obtain physician's orders for OT services. Review of the referral from Denver Health Hospital Authority, dated 2/2/22 and signed by the physician, indicated the need for home health OT services. Review of the request for authorization from Denver Health dated 2/18/22, not signed by a physician, indicated authorization for seven OT visits. Review of the home health certification and plan of care with start of care date 2/7/22 for the certification period dated 2/7/22 to 4/7/22, showed it was not signed by a clinician or the physician, and revealed an OT frequency of one time for one week, then two times a week for three weeks. Review of a verbal order dated 2/15/22 at 15:13 p.m., completed by OT #11, showed documentation an order was received from the physician's representative for an effective date of 2/6/22 for OT once week for one week and twice a week for three weeks. The Verbal order was never signed by the physician. Review of the clinical record revealed Patient #2 was seen six times by the OT: 2/7/22, 2/25/22, 3/1/22, 3/3/22, 3/7/22 and 3/11/22. None of these visits had been approved by a physician. During an interview 4/12/22 at 9:05 a.m. OT #11 stated she had discontinued services for Patient #2 because all goals were met. She further stated she completed a discharge summary and was uncertain as to where the discontinuation orders were. 2. The clinical record for Patient #7 was reviewed on 4/12/22. Review of the plan of care for the certification period dated 12/14/21 to 2/11/22 revealed a start of care of 12/14/21; diagnoses included Ischemic cardiomyopathy exacerbation, atherosclerotic heart disease (ASHD), other specific depressive episodes, type 2 diabetes mellitus without complications, and contusion of the right knee. Plan of care orders included; SN once weekly on Wednesday to assess and evaluate wound V.A.C. (vacuum assisted closure of a wound) dressing change, PT and OT to assess, evaluate and treat. a) The SN failed to ensure orders were obtained for SN services. Review of the signed referral dated 12/11/22 revealed Patient #7 was ordered to receive home health for SN, PT and OT services. Review of the plan of care plus dated 12/14/21 revealed an order for SN every Wednesday for wound V.A.C. dressing change and assessment. Review of the clinical record revealed RN #4 saw Patient #7 two times, 12/14/21 for the comprehensive assessment and again on 12/22/21, for a routine visit. The clinical record failed to reveal any further skilled nursing visit notes. Review of the electronic medical record scheduler, revealed RN #4 documented missed visits on Wednesday 12/29/21 and every Wednesday in January 2022 as the patient was hospitalized. Review of a requested order written on 2/16/22 by RN #4 stated to discontinue SN services, however it did not state who was spoken to nor was it signed by a physician. Review of the clinical record failed to reveal any services being provided after 1/11/22. During an interview on 4/13/22 at 11:45 a.m., the DON stated she looked for tiger texts about this case and was not able to find any, she further stated that it was past the 30-day mark that tiger text keeps communication but she would attempt to obtain the archived communications. The DON failed to present the SA with any tiger text documentation. During an interview on 4/13/22 at 2:07 p.m., RN # 4 verified she saw Patient #7 on 12/14/21 to start the case, then again on 12/22/21. After that she documented missed visits for 12/29/21 and every Wednesday in January, because the patient was in a rehab facility. She further stated that she was in Russia for the month of January and not working for the agency. During an interview on 4/12/22 at 12:57 p.m., RN #4 stated she had conversions about Patient #7 with his physician and the patient's wife, however she did not document the conversations and felt she may have used tiger text (a form of instant messaging) to communicate with office staff and other clinicians. During an interview on 4/13/22 at 1:59 p.m., a representative at Patient #7's physician's office stated they had not seen or had communication about Patient #7 since 1/10/22 when he was seen in the office. He further stated he had no communication from the agency about the patient. b) The agency failed to ensure orders were obtained for OT services. Review of the signed referral dated 12/11/22 revealed Patient #7 was ordered to receive home health for SN, PT and OT services. Review of the plan of care plus dated 12/14/21, not signed by the physician revealed orders for OT to assess, evaluate and treat. Review of the clinical record failed to reveal a frequency or duration order for OT services. Review of the clinical record revealed OT #5 saw Patient #7 on 12/16/21 for the evaluation then again on 12/23/21 for a routine visit. Review of the occupational therapy note dated 12/23/21 and completed by OT #5, revealed Patient #7 was making progress towards goals but those goals were not met and four to six more weeks of therapy was needed. There was no indication if the plan of care had been discussed with or ordered by the physician. During an interview on 4/12/22 at 8:48 a.m., OT #5 stated she did not recall providing service to Patient #7. She further stated she might have received a tiger text communication about it. c) The agency failed to ensure orders were obtained for PT services. Review of the signed referral dated 12/11/22 revealed Patient #7 was ordered to receive home health for SN, PT and OT services. Review of the plan of care plus dated 12/14/21 revealed orders for PT to assess, evaluate and treat. Skilled PT visits were completed on 1/6/22 and 1/11/22, for a total of 2 visits. Review of the physical therapy assessment dated 1/6/22 revealed Patient #7 was in need of PT services two times a week for four weeks. There was no indication if the plan of care had been discussed with or ordered by the physician During an interview on 4/12/22 at 12:34 p.m., PT #3 stated he was not working for the agency in December and that he started with them on 1/5/22, so he did the evaluation on 1/6/22. PT #3 further stated that Patient #7 wanted to go back to work so he discontinued services for him. During an interview on 4/12/22 at 2:10 p.m., the administrator stated PT #3 may have had his patients confused as they had two patients with the same last name. A call was placed to PT #3 on 4/13/22 at 11:09 a.m. however no answer was received. A voice mail was left requesting a call back to again discuss Patient #7, but no return call was received by the exit time 4/14/22 at 9:45 a.m. 3. The clinical record for Patient #3 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/8/22 to 4/8/22, revealed a start of care date of 2/8/22; diagnoses included; essential hypertension (high blood pressure), type 2 diabetes mellitus without complications, and COVID 19. Plan of care orders included; SN one time only for comprehensive assessment, PT to assess, evaluate and treat, OT to assess, evaluate and treat. a) The agency failed to ensure start of care orders were received for PT and OT to provide services. Review of the discharge plan from the hospital dated 2/4/22 at 12:42 p.m. indicated the agency was to provide home health services for PT, OT, and SN Review of the plan of care plus form dated, 2/9/22 for the certification period dated 2/8/22 to 4/8/22, and not signed by the physician, indicated a need for PT and OT to evaluate and treat. Review of the clinical record revealed a requested order, dated 2/11/22 at 18:57 p.m., not signed by the physician for OT to evaluate only, then discontinue services. The clinical record revealed that both PT and OT did an evaluation. PT on 2/9/22 and OT on 2/11/22. The clinical record failed to reveal any evidence of signed orders for PT or OT services. During an interview on 4/12/22 at 12:37 p.m., PT #3 stated this was an issue with a previous employee not following up on orders. During an interview on 4/12/22 at 1:45 p.m., the administrator stated she could not find any signed orders for Patient #3. 4. The clinical record for Patient #4 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/1/22 to 4/1/22 revealed a SOC date of 2/1/22; diagnoses included heart failure, difficulty in walking. Plan of care orders included PT two times per week for four weeks to provide therapeutic exercises, therapeutic activities, neuro reeducation, gait and transfer training; OT one time a week for two weeks, two times a week for two weeks to evaluate, establish and teach home exercise program, independent living training, teach activities of daily living (ADLs) skills and therapeutic exercise. However the request was not signed by the physician. a) The agency failed to obtain physician orders for PT services. Review of the Denver Health authorization form dated 2/10/22 indicated authorization approval for seven PT visits, for a service start date of 2/1/22 and an end date of 3/2/22. Review of the plan of care plus form dated 2/1/22, and not signed by the physician, revealed under the clinical summary portion of the form, that Patient #4 would benefit from skilled PT two times a week for four weeks. Review of the requested order dated 2/28/22 at 21:59 p.m., signed by PT #3, indicated a request for PT to evaluate, establish, upgrade, teach home exercise program, therapeutic exercise, transfer training, gait training, balance training, teach body mechanics, back precautions for a duration of twice a week for two weeks, then once for one week. However the request was not signed by the physician. Further record review failed to reveal any orders for services signed by the physician. Review of the clinical record revealed PT visits were completed on; 2/1/22, 2/17/22, 2/22/22, 2/23/22, and 2/28/22. For a total of 5 visits completed without physician orders. During an interview on 4/12/22 at 12:25 p.m., PT #3, stated most of the time he left a message for the physician at his or her office and then wrote the "verbal order". He further stated he did not track the verbal order for signature but did wait until the office called him back before seeing patients. b) The agency failed to obtain physician orders for OT services. Review of the Denver Health authorization form dated 2/10/22 indicates authorization approval for one OT visit, for a service start date of 2/1/22 and an end date of 3/2/22. Review of the home health certification and plan of care form, with start of care date 2/1/22 for certification period dated 2/1/22 to 4/1/22, not signed by the physician, indicated for OT to evaluate and treat. Review of the requested order dated 2/28/22 21:59 p.m., signed by PT #3, indicated the request for OT evaluation, establish, upgrade, teach home exercise program, independent living/ADL training, creation and training of adaptive equipment, tech alternative ADL skills, teach safe , effective use of adaptive, assistive devices, therapeutic exercises for one time for one week, twice a week for two weeks then once a week for one week. However, the request was not signed by the physician. Review of the clinical record revealed OT visits were completed on; 2/2/22, 2/18/22, 2/21/22, 2/23/22, 3/2/22, 3/7/22 and 3/14/22. For a total of seven visits completed without physician orders. During an interview on 4/12/22 at 9:00 a.m., OT #7 stated the agency office was in charge of tracking verbal orders but did not follow up with them. He continued to state that the electronic medical record (EMR) generated the plan of care from the start of care date, even if that was not when the order was received. During an interview on 4/13/22 at 4:13 p.m. the DON stated that when she was in the field she followed up on her orders but believed it to be an office process that needed to be followed up on. 5. The clinical record for Patient #6 was reviewed on 4/12/22. Review of the plan of care for the certification period of 1/31//22 to 3/31/22 revealed a SOC date of 1/31/22; diagnoses included acute post procedural pain, intervertebral disc displacement, lumbar region, type 2 diabetes mellitus without complications and essential hypertension. Plan of care orders included PT two times per week for four weeks to establish and teach home exercise program, therapeutic exercise, transfer, gait and balance training and to teach fall safety and body mechanic precautions. a) The agency failed to obtain physician orders for PT services. Review of the clinical record revealed a plan of care plus form dated 1/31/22 for the certification period dated 1/27/22 to 3/27/22, not signed by the physician or clinician, indicated in the clinical summary portion of the form for skilled PT services two times a week for four weeks, to include therapeutic exercises, therapeutic activities, neuro re-education, gait and transfer training. Review of the signed face-to face encounter form dated 1/12/22 indicated the need for home therapy. Review of the clinical record failed to to show an order had been obtained by the agency to provide care. Review of the requested order dated 1/31/22 at 10:05 a.m. completed by PT # 3, revealed the need for skilled PT services two times per week for four weeks for therapeutic exercise, therapeutic activities, neuro re-education, gait and transfer training. However the requested order had not been signed by the physician. Further review of the clinical record revealed PT visits were completed on the following dates by various PT's; 1/31/22, 2/23/22, 2/25/22, 3/3/22, 3/8/22, 3/10/22, 3/15/22, 3/24/22, 3/28/22 and 3/29/22. A total of ten visits were made without physician orders. Review of requested order dated 2/23/22 at 21:24 p.m., by PT #3 indicated the need for PT to evaluate, establish, upgrade, teach home exercise program, therapeutic exercise, transfer training, gait training, balance training, teach fall safety, teach body dynamics, back precautions, frequency and duration: twice a week for four weeks. However, there was no evidence of the request being communicated with the physician nor was it signed by the physician. During an interview on 4/12/22 at 12:30 p.m., PT #3 stated he recalled Patient #6 and often services were refused, so he missed a month of visits, but obtained a new order and did a new evaluation on 2/23/22. He did not recall the whereabouts of any of the orders. 6. The clinical record for Patient #8 was reviewed on 4/13/22. Review of the plan of care for the certification period 3/4/22 to 5/2/22 revealed a start of care of 3/4/22; diagnoses included; Nondisplaced intertrochanteric fracture of the left femur, encounter for surgical aftercare following surgery on the nervous system, memory deficit following cerebral infarction, other signs and symptoms of cognitive functions following a cerebral infarction, dysphagia following cerebral infarction, hypertensive heart disease. Plan of care orders included; PT one time for one week then two times a week for three weeks, to provide treatment to include therapeutic exercises, therapeutic activities, neuro re-education, gait training and transfer training, OT had no frequency or duration only to assess, evaluate and treat. a) The agency failed to ensure orders were received for PT services. Review of the signed referral order dated 2/26/22 indicated the need for home health skilled services for PT, OT, ST and MSW. Review of the authorization for services form, from professional health care network, dated 2/25/22; indicated authorization for three PT visits. Review of the clinical record revealed a plan of care plus form dated 3/4/22 for the certification period dated 3/4/22 to 5/2/22, not signed by the physician, indicated the need for skilled PT once for one week then twice a week for three weeks. Review of the clinical record revealed PT visits were completed on 3/9/22 and 3/11/22. For a total of three visits completed without physician orders. The clinical record failed to reveal evidence of any physician approved orders for frequency or duration of skilled PT services. A call was placed to PT #3 on 4/13/22 at 11:09 a.m. however no answer was received. A voice mail was left requesting a call back to again discuss Patient #7, but no return call was received by the exit time on 4/14/22 at 9:45 a.m. b) The agency failed to ensure orders were received for OT services. Review of the signed referral order dated 2/26/22 indicated the need for home health skilled services for PT, OT, ST and MSW. Review of the authorization for services form, from professional health care network, dated 2/25/22; indicated authorization for one OT visit. Review of the clinical record revealed a plan of care plus form dated 3/4/22 for the certification period of 3/4/22 to 5/2/22, not signed by the physician, which indicated the need for skilled OT to assess, evaluate and treat. Review of the clinical record revealed OT did evaluations on 3/9/22 and 3/16/22. For a total of two visits completed without physician orders. Review of the OT evaluation note dated 3/16/22, revealed OT discharge completed as OT goals were met. The clinical record failed to reveal evidence of any physician approved orders for frequency or duration for skilled OT services. During an interview on 4/13/22 at 2:57 p.m., OT #7 stated he thought the orders were automatically generated in the EMR and no one had told him otherwise. He further stated he believed PT was still seeing Patient #8. 7. During an interview on 4/13/22 at 4:40 p.m., the DON stated that since taking on the DON role she realized there was no process in place for tracking orders. She further stated she felt orders were being obtained retroactively. During an interview on 4/13/22 at 4:30 p.m., Employee # 9, confirmed there was little to no process for following up on orders and that was why he asked the administrator to hire a DON and ADON.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT 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 in 7 of 10 patient records reviewed (Patients #2, #3, #4, #5, #6, #7 and #8). Findings include: 1. The clinical record for Patient #2 was reviewed on 4/11/22. Review of the plan of care for the certification period dated2/7/22 to 4/7/22 revealed a start of care date (SOC) of 2/7/22; diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, hypoxemia, thrombocytopenia and bipolar disorder. Plan of care orders included; physical therapy (PT) one time a week for one week, two times a week for three weeks to establish and teach home exercise program, evaluation, therapeutic exercise, gait training, functional mobility training and to teach fall safety; occupational therapy (OT) one time a week for one week, two times a week for three weeks to provide evaluation, establish home exercise program, independent living training, teach activities of daily living (ADLs) skills, therapeutic exercise and energy conservation techniques; and skilled nursing (SN) one time a week for four weeks for evaluation, medication (no specifics provided) and symptom management. a) The agency failed to ensure communication with all physicians involved in the plan of care. Clinical record review showed a referral from Denver Health Hospital Authority, dated 2/2/22, and signed by Dr. Lande, requesting a home health services evaluation for SN, PT, and OT. Review showed a SOC comprehensive assessment and plan of care was completed on 2/7/22 for the certification period dated 2/7/22 to 4/7/22 by registered nurse (RN) #10 indicating the need for SN once a week for four weeks had been automatically faxed to the physician; however, had not been returned signed by the physician within the certification period. Review of the orders history between 2/7/22 to 4/11/22 revealed the agency had maintained order requests to the physician throughout the certification period and that all order requests called verbal orders that were documented as sent to the physician for review were not returned with signature. The record failed to reveal further communication or confirmation that request orders were received by the physician and authenticated with signatures as orders. -PT order request dated 2/11/22 that read: "Effective 2/11/2022: Assessment and intervention of Physical Therapy 1w1, 2w3" had been automatically faxed to the physician on 2/11/22; however, had not been returned signed by the physician within the certification period. -OT order request dated 2/11/22 that read: "Effective 2/7/2022: OT Orders Evaluation, POC development/management, Establish/Upgrade/Teach Home Exercise Program, Independent living/ADL training, Teach alternate ADL skills, Therapeutic Exercise, Other: Energy conservation techniques Frequency and Duration: 1w1, 2w3" had been automatically faxed to the physician on 2/13/22; however, had not been returned signed by the physician within the certification period. -PT and OT verbal order dated 2/14/22 that read: "Late entry for 2/14/2022 at 8:00AM: VO received from Emma, RN on behalf of Dr. Lande, approving OT frequency of 1w1 and 2w3 effective 2/6/22. OT Orders Evaluation, POC development/management, Establish/Upgrade/Teach Home Exercise Program, Independent living/ADL training, Teach Alternate ADL skills, Therapeutic Exercise, Other: Energy conservation techniques Frequency and Duration: 1w1, 2w3." had been automatically faxed to the physician on 2/15/22; however, had not been returned signed by the physician within the certification period. -SN verbal order dated 2/22/22 that read: "Effective 2/17/22: Late entry for 2/17/22. SN discipline only discharge. Goals met. Patient and cg agrees with the plan. Consult nursing as needed. VO. Emily/Dr. Lande" had been automatically faxed to the physician on 2/22/22; however, had not been returned signed by the physician within the certification period. And, -OT continuation of care order request dated 3/4/22 that read: "Effective 3/4/22: Physical therapist requesting coco 1w1, 2w3" had been automatically faxed to the physician on 3/8/22; however, had not been returned signed by the physician within the certification period. RN #10 was not available for an interview as she was no longer with the agency. b) The agency failed to coordinate with the physician before discontinuing OT services to Patient #2. Review showed a plan of care was completed on 2/7/22 for the certification period dated 2/7/22 to 4/7/22 by registered nurse (RN) #10 indicating the need for OT frequency of one time for one week, then two times a week for three weeks. The plan of care had been automatically faxed to the physician; however, had not been returned signed by the physician within the certification period. Review of the OT specific documentation revealed a discipline-specific discharge completed by OT #11 on 3/11/22 and included communication with Patient #2 and caregiver; however, the record failed to reveal documentation that the physician had been notified of the revision. c) The agency failed to coordinate with the physician before discontinuing PT services to Patient #2 Review showed a plan of care was completed on 2/7/22 for the certification period dated 2/7/22 to 4/7/22 by registered nurse (RN) #10 indicating the need for PT frequency of one time for one week, then two times a week for three weeks. The plan of care had been automatically faxed to the physician; however, had not been returned signed by the physician within the certification period. Review of the PT specific documentation revealed PT #12 had completed a visit on 3/15/22; however, there had not been visits completed since then. The record failed to reveal documentation explaining why services were no longer provided to Patient #2, or of communication to the physician regarding revision to the plan of care. During an interview on 4/13/22 at 10:45 a.m., Patient #2's caregiver stated they were aware that the OT had notified the physician of discipline-specific discharge on 3/11/22 due to a recent discussion with the physician; however, had not been aware if PT had communicated service hold with the physician. d) During an interview on 4/12/22 at 2:14 p.m., the administrator reviewed Patient #2's record and acknowledged there was no documentation of communication with the physician regarding services. The administrator reviewed all unsigned verbal orders and the unsigned plan of care for Patient #2 and confirmed the agency had failed to ensure communication with the physician had been completed. The administrator stated there was no staff monitoring communication with the physicians to ensure they were completed and included within the record. 2. The clinical record for Patient #5 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/11/22 to 4/11/22 revealed a SOC date of 2/11/22; diagnosis included; fracture of neck, fusion of spine and failure to thrive. Plan of care orders included; SN daily to provide wound care, home health aide (HHA) with no frequency or duration to provide assistance with personal care and assistance with ADLs, Medical Social Worker (MSW) with no frequency or duration to evaluate the living situation and provide a support system; PT one time a week for five weeks to establish, upgrade, teach and provide education, therapeutic exercises, gait and transfer training, muscle re-education and energy conservation; and OT one time a week for six weeks to evaluate, establish, upgrade, teach and provide a home exercise program, independent living skills, training of equipment and therapeutic exercises. a) The agency failed to ensure communication with all physicians involved in the plan of care. Review of the SOC assessment and plan of care completed for the certification period dated 2/11/22 to 4/11/22, completed by the director of nursing (DON) on 2/10/22, was reviewed and signed by the physician on 3/1/22. The plan of care included orders for SN services daily for wound care, PT services one time a week for five weeks effective 2/17/22 and OT services one time a week for six weeks effective 2/17/22. Review of the record revealed the DON first provided services on 2/20/22, one week after the SOC. The record failed to reveal documentation to explain the reason visits were not completed or a record of communication to the physician regarding the eight missed visits during this time. Review of the record revealed PT #3 had not completed a scheduled visit the week of 3/20/22 to 3/27/22 and the record failed to reveal documentation to provide a reason the visit was not completed or that the physician had been notified. Additionally, record review revealed PT #3 completed an evaluation on 3/29/22; however, the record failed to reveal a physician's order had been obtained for a new evaluation. During an interview on 4/11/22 at 2:55 p.m., the DON, who had completed the SOC and SN visit on 2/20/22 stated they had attempted scheduled visits to Patient #5; however, Patient #5 had resided in a shelter and was often not available. The DON reviewed Patient #5's record and acknowledged there was no documentation of attempted visits or notification to the physician of the missed visits. During an interview on 4/13/22 at 10:49 a.m., a representative from Patient #5's physician office reviewed the communication between the agency and physician and their (the physician's office) record failed to reveal communication from the PT or OT regarding services at all; DON communication had included discipline specific discharge orders; however, failed to reveal communication of SN missed visits. 3. The clinical record for Patient #7 was reviewed on 4/12/22. Review of the plan of care for the certification period 12/14/21 to 2/11/22 revealed a SOC of 12/14/21; diagnoses included ischemic cardiomyopathy exacerbation, athrolsclerotic heart heart disaese (ASHD), other specific depressive episodes, type 2 diabetes mellitus without complications, and contusion of the right knee. Plan of care orders included; SN once weekly to assess and evaluate wound V.A.C. (vacuum assisted closure) dressing change, PT had no duration or frequency listed to assess, evaluate and treat; and OT had no duration or frequency listed to assess, evaluate and treat. a) The agency failed to ensure communication with all physicians involved in the plan of care. Review of the signed referral, dated 12/11/22, revealed Patient #7 was ordered to receive home health for SN, PT and OT services. Review of the plan of care, dated 12/14/21, revealed an order for SN every Wednesday for wound V.A.C. dressing change and assessment; OT services to assess, evaluate and treat without a frequency or duration and PT services to assess, evaluate and treat without a frequency or duration. The plan of care was automatically faxed to the physician on 12/14/21; however, had not been returned signed by the physician within the certification period. Review of the visit record between 12/14/21 to 4/11/22 revealed RN #4 completed the SOC on 12/14/21 and one other SN visit on 12/22/21, with no other SN visits after; OT #5 completed an evaluation on 12/16/21 and a visit on 12/23/21, with no other OT visits after; and PT #3 had completed an evaluation on 1/6/22 and a visit on 1/11/22, with no other PT visits after. The record failed to reveal documentation to explain why services were not provided in accordance to the plan of care or documentation the physician had been notified for each discipline's revision to the plan of care. RN #4 stated Patient #7 had been hospitalized and later admitted to a skilled nursing facility for long term care. RN #4 completed a request order for Patient #7 from the agency on 2/16/22. The record failed to reveal documentation of communication regarding the discharge or that the physician had been notified. During an interview on 4/12/22 at 11:45 a.m., the DON attempted to review the agency's internal communication via tigertext; however, the communication had been archived; therefore, documentation of Patient #7's care coordination was not available for review, including any notification to the physician. The DON confirmed all communication regarding patient care must be maintained within the patient record. During an interview on 4/13/22 at 1:59 p.m., a representative from Patient #7's physician office reviewed orders and communication between the agency and the physician and stated Patient #7 had been seen by the physician in a long term care facility on 1/10/22 and did not have orders for home care at that time. However, record review showed the agency should have provided 2 SN visits and 2 OT visits between 12/23/22 to 1/10/22. A PT evaluation ordered at SOC on 12/14/21 had not been provided until 1/6/22 without documentation of why PT evaluation was delayed or if the patient or physician had been notified of the delay. 4. The clinical record for Patient #3 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/8/22 to 4/8/22 revealed a SOC date of 2/8/22; diagnoses included essential hypertension, type 2 diabetes mellitus without complications and COVID-19. Plan of care orders included; PT two times a week for four weeks for decreased functional mobility. a) The agency failed to ensure communication with all physicians involved in the plan of care. Review of the record revealed PT #13 completed a PT evaluation on 2/9/22 and scheduled visits between 2/11/22-3/7/22 were declined by patient which PT #13 completed missed visit documentation and was acknowledged by the physician. However, services were not documented as having been attempted following 3/7/22, a discharge from PT or from the agency had not been completed and submitted to the physician for review and any further communication with Patient #3 had not been documented. During an interview on 4/13/22 at 10:40 a.m., Patient #3 confirmed PT services were no longer needed and Patient #3 had been discharged from the agency. An attempt to interview the physicians' office was completed on 4/13/22 at 2:14 p.m. without a response. During an interview on 4/12/22 at 1:45 p.m., the administrator reviewed the record and confirmed there was no documentation PT #13 had communicated with the physician any revision to the plan of care, including a need for discharge, following 3/7/22. 5. The clinical record for Patient #4 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/1/22 to 4/1/22 revealed a SOC date of 2/1/22; diagnoses included heart failure and difficulty in walking. Plan of care orders included PT two times per week for four weeks to provide therapeutic exercises, therapeutic activities, neuro re-education and gait and transfer training; OT one time a week for two weeks, two times a week for two weeks to evaluate, establish and teach home exercise program, independent living training, teach ADLs and provide therapeutic exercise. a) The agency failed to ensure communication with all physicians involved in the plan of care. Review of the record between 2/1/22 to 4/11/22 revealed PT #3 had completed an evaluation for SOC on 2/1/22 and a verbal order for OT evaluation and treatment effective 2/1/22 was returned signed by the physician on 2/7/22. The SOC evaluation revealed PT services were needed two times per week for four weeks to provide therapeutic exercises, therapeutic activities, neuro re-education and gait and transfer training. Following the SOC, services were not provided until PT #3 completed a routine visit on 2/17/22. The record failed to reveal documentation to explain why services were not provided for the three scheduled PT visits between 2/2/22 to 2/16/22, or if the agency had communicated with the physician. Review of the completed visit notes revealed PT #3 provided services on four visits in total, dated: 2/17/22, 2/22/22, 2/24/22 and 2/28/22. The record revealed on 2/28/22 a verbal order requested via voicemail to the physician to continue PT services at two times a week for two weeks and one time a week for one week as well as OT services as 1 time a week for two weeks and two times a week for two weeks had been completed; however, this order request had not been returned to the agency with physician signature and the record failed to reveal any confirmation the order was received by the physician. Following 2/28/22, the record failed to reveal documentation to explain why PT services were no longer provided or communication to the physician. During an interview on 4/12/22 at 12:25 p.m., PT #3 stated they had completed the SOC assessment on 2/1/22; however, believed another PT was to complete the patient care ongoing; therefore, they had not followed up on Patient #4's care. On 2/17/22, PT #3 began providing PT services to Patient #4 ongoing. PT #3 stated services were not provided after 2/28/22 due to staffing concerns and the agency was unable to meet the needs of Patient #3 at the time. Further, PT #3 stated they had not followed up on the verbal order to continue PT services created on 2/28/22 and had not notified the physician that PT services were not provided following 2/28/22 in accordance with the plan of care. 6. The clinical record for Patient #6 was reviewed on 4/12/22. Review of the plan of care for the certification period dated 1/27/22 to 3/27/22 revealed a SOC date of 1/31/22; diagnoses included acute postprocedural pain, intervertebral disc displacement, lumbar region, type 2 diabetes mellitus without complications and essential hypertension. Plan of care orders included; PT two times per week for four weeks to establish and teach home exercise program, therapeutic exercise, transfer, gait and balance training and to teach fall safety and body mechanic precautions. a) The agency failed to ensure communication with all physicians involved in the plan of care. Review of the clinical record revealed a plan of care dated 1/31/22 for the certification period dated 1/27/22 to 3/27/22, not signed by the physician or clinician, indicated the need for skilled PT services two times a week for four weeks to include therapeutic exercises, therapeutic activities, neuro re-education, gait and transfer training. The plan of care was automatically faxed to the physician on 1/31/22; however, had not been returned signed by the physician within the certification period. Review of the PT discipline specific documentation revealed PT services were not provided between the SOC on 1/31/22 and 2/22/22 and the record failed to reveal a documented explanation to why services were not provided or that the physician was notified of the five missed PT visits. During an interview on 4/12/22 at 12:30 p.m., PT #3 stated Patient #6 had declined PT due to ongoing pain and eventually had agreed to PT services to begin on 2/23/22. PT #3 reviewed the record and confirmed there was no documentation of this communication with the patient or that the physician had been notified of revision to orders. During an interview on 14/14/22 at 7:30 a.m., Patient #6's caregiver stated the agency had a malfunctioning fax machine for several weeks during the beginning of services and was aware that patient care had been delayed due to inability to receive or send faxed orders from physician or insurance authorization. Patient #6's caregiver stated services and communication had improved at the agency; however, was unsure of the communication between the agency and physician ongoing. b) The agency failed to ensure the physician was notified of a recertification period. Review of the record revealed Patient #6's certification period dated 1/27/22 to 3/27/22 failed to reveal a recertification assessment completed and provided to the physician. A new certification period beginning on 3/28/22 revealed Patient #6 had received PT services on 4/4/22, 4/6/22 and 4/11/22 without notification to the physician that services were continued into another certification period. Review of the record failed to reveal a new plan of care had been created for the new certification period to be shared with the physician in continuation of PT services. During an interview on 4/12/22 at approximately 12:30 p.m., PT #3 stated they were not aware a recertification assessment was due and therefore had not completed an assessment or notification to the physician regarding a new certification period. c) An attempted interview with Patient #6's physician office was completed on 4/13/22 at 11:35 a.m. without a response. During an interview on 4/13/22 at 4:14 p.m., the DON stated individual clinicians were to monitor certification end dates, insurance authorizations and calendar notifications regarding need for reassessments and this recertification should not have been missed. The DON confirmed that all patient related communication should be maintained within the patient record for continuity of care. 7. The clinical record for Patient #8 was reviewed on 4/13/22. Review of the plan of care for the certification period dated 3/4/22 to 5/2/22 revealed a SOC of 3/4/22; diagnoses included; nondisplaced intertrochanteric fracture of the left femur, encounter for surgical aftercare following surgery on the nervous system, memory deficit following cerebral infarction, other signs and symptoms of cognitive functions following a cerebral infarction, dysphagia following cerebral infarction, hypertensive heart disease. Plan of care orders included; PT one time for one week then two times a week for three weeks, to provide treatment to include therapeutic exercises, therapeutic activities, neuro re-education, gait training and transfer training, OT had no frequency or duration only to assess, evaluate and treat. a) The agency failed to ensure communication with all physicians involved in the plan of care. Review of the SOC assessment and plan of care dated 3/4/22 for the certification period dated 3/4/22 to 5/2/22, not signed by the physician, indicated the need for skilled PT once for one week then twice a week for three weeks to provide therapeutic exercises, therapeutic activities, neuro re-education, gait training and transfer training. The SOC further included a need for OT to assess, evaluate and treat. Review of the PT completed visits revealed services were provided on 3/9/22 and 3/11/22 and were not provided ongoing after 3/11/22. The record failed to reveal documentation the physician was notified of changes to the plan of care or justification to why there had been a revision. A call was placed to PT #3 on 4/13/22 at 11:09 a.m. however no answer was received. A voice mail was left requesting a call back to again discuss Patient #7, but no return call was received by the exit time on 4/14/22 at 9:45 a.m. b) The agency failed to coordinate OT services with the physician. Review of the authorization for services form, from professional health care network, dated 2/25/22; indicated authorization for one OT visit. Review of the OT completed visits revealed OT evaluated Patient #8 for services on 3/9/22 and on 3/16/22 completed OT specific discharge due to goals having been met. The record failed to reveal documentation the physician was notified of the discharge. During an interview on 4/13/22 at 2:46 p.m., OT #7 stated physician orders were generated automatically and sent to the physician and that a member of the office management monitored physician orders received with signature. c) During an interview on 4/13/22 at 2:15 p.m., the DON stated Employee #9 scanned received paperwork into the appropriate patient record; however, there had not been office staff monitoring that physician orders were received timely.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure coordination in care delivery met the patients’ needs and involved the patient and caregivers as appropriate in 7 of 10 patient records reviewed (Patients #2, #3, #4, #5, #6, #7 and #8). Findings include: 1. The clinical record for Patient #2 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/7/22 to 4/7/22 revealed a start of care (SOC) date of 2/7/22; diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, hypoxemia, thrombocytopenia and bipolar disorder. Plan of care orders included; physical therapy (PT) one time a week for one week, two times a week for three weeks to establish and teach home exercise program, evaluation, therapeutic exercise, gait training, functional mobility training and to teach fall safety; occupational therapy (OT) one time a week for one week, two times a week for three weeks to provide evaluation, establish home exercise program, independent living training, teach activities of daily living (ADLs) skills, therapeutic exercise and energy conservation techniques; and skilled nursing (SN) one time a week for four weeks for evaluation, medication (no specifics provided) and symptom management. a. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, the PT failed to communicate with internal agency office management to ensure ongoing services were authorized to be provided in accordance with the plan of care. Review of the request for authorization from Denver health dated 2/19/22, not signed by a physician, indicated approval for seven PT visits from 2/7/22 to 4/7/22. Review of the plan of care, with start of care date 2/7/22 for the certification period of 2/7/22 to 4/7/22, not signed by a clinician or the physician, indicated a PT frequency of one time for one week, then two times a week for three weeks to establish and teach home exercise program, evaluation, therapeutic exercise, gait training, functional mobility training and to teach fall safety. Review of the PT specific documentation revealed PT #12 had completed a visit on 3/15/22; however, there had not been visits completed since then. The record failed to reveal documentation explaining why services were no longer provided to Patient #2, or of communication to the patient regarding revision to the plan of care. During an interview on 4/12/22 at 8:43 a.m., PT #12 stated Patient #2 had been on hold due to an insurance authorization lapse which office management tracked. PT #12 stated the clinician was to notify the office management when an insurance authorization was going to lapse prior to the last visit and office management was to resend an authorization request for services prior to a lapse in care. PT #12 stated Patient #2 and caregiver were aware of the reason services were on hold; however, acknowledged this communication had not been maintained in the record. During an interview on 4/12/22 at 2:14 p.m., the administrator reviewed Patient #2's record and acknowledged there was no documentation of communication with the patient or caregiver regarding services. The administrator stated a review of the internal agency communication system (tigertext) revealed PT services were on hold until insurance authorization had been received and Patient #2 maintained as an active patient of the agency. The administrator confirmed the process that clinicians were to notify office management prior to a lapse in coverage in order to provide continuity of care. The administrator stated per tigertext communication an insurance authorization had been requested on 3/21/22, after the last provided PT visit. The administrator stated it was not clear when PT #12 had notified the office management of the need to submit a new insurance authorization to avoid the lapse in patient care. During an interview on 4/13/22 at 10:45 a.m., Patient #2's caregiver stated the agency had been in communication with the patient and caregiver regarding revisions to the plan of care due to the pending insurance authorization at the last PT visit on 3/15/22; however, had not had communication between 3/15/22 to 4/12/22, when the caregiver called to inquire about progress. Patient #2's caregiver further stated Patient #2 had declined in ADLs since the last PT visit and the caregiver had increased concern of Patient #2's risk of falling and re-hospitalization without services in the home. 2. The clinical record for Patient #5 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/11/22 to 4/11/22 revealed a SOC date of 2/11/22; diagnoses included; fracture of neck, fusion of spine and failure to thrive. Plan of care orders included; SN daily to provide wound care, home health aide (HHA) with no frequency or duration to provide assistance with personal care and assistance with ADLs, Medical Social Worker (MSW) with no frequency or duration to evaluate the living situation and provide a support system; PT one time a week for five weeks to establish, upgrade, teach and provide education, therapeutic exercises, gait and transfer training, muscle re-education and energy conservation; and OT one time a week for six weeks to evaluate, establish, upgrade, teach and provide a home exercise program, independent living skills, training of equipment and therapeutic exercises. a. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, the registered nurse (RN) failed to communicate with the patient and care team regarding patient needs. Review of the SOC assessment dated and plan of care dated 2/11/22 for the certification period of 2/11/22 to 4/11/22, signed by a physician on 3/1/22, indicated the need for SN services once per day for observation and assessment of integumentary system for wound care. Review of the record revealed the director of nursing (DON) first provided services on 2/20/22, two weeks after the SOC. The record revealed SN discharged on 2/24/22 due to the wound being healed. The record failed to reveal documentation to explain the reason visits were not completed or a record of communication to the patient regarding missed visits during these two weeks. During an interview on 4/11/22 at 2:55 p.m., the DON, who completed the SOC and SN visit on 2/20/22, stated they had attempted scheduled visits to Patient #5; however, Patient #5 had resided in a shelter and was often not available. The DON reviewed Patient #5's record and acknowledged there was no documentation of attempted visits or attempted communication with the patient regarding the missed visits. Further, the record failed to reveal communication with other disciplines, PT and OT, that were to provide services to Patient #5. b. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, the PT failed to communicate with the patient and care team regarding patient needs. Review of the plan of care, with start of care date 2/11/22 for the certification period of 2/11/22 to 4/11/22, signed by a physician on 3/1/22, indicated a need for PT services one time a week for five weeks. Review of the PT discipline specific record revealed PT #3 had not completed a scheduled visit in accordance with the plan of care the week of 3/20/22 to 3/27/22 and the record failed to reveal documentation to provide a reason the visit was not completed or that the patient was notified of the change. During an interview on 4/12/22 at 10:40 a.m., the DON reviewed Patient #5's record and confirmed the record failed to reveal documentation to explain why PT #3 had missed a visit; however, the director of nursing reviewed the agency's internal communication via tigertext which stated PT #3 had a scheduled visit with Patient #5 the week of 3/20/22 to 3/27/22 and the visit had been rescheduled to 3/29/22 due to patient availability. The DON acknowledged that all patient communication needed to be included within the patient record for continuity of care. c. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, the OT failed to communicate with the patient and care team regarding patient needs. Review of the plan of care, with start of care date 2/11/22 for the certification period of 2/11/22 to 4/11/22, signed by a physician on 3/1/22, indicated a need for an OT evaluation. The OT evaluation completed on 2/18/22 by OT #5 indicated a need for OT services one time a week for six weeks. An order request for this frequency was completed on 2/21/22; however, not returned signed by a physician. Review of the OT discipline specific record revealed OT #5 had not completed a visit after 3/3/22 without justification for the missed visits or communication with the patient's care team. During an interview on 4/12/22 at 8:48 a.m., OT #5 stated OT services were discharged on 3/3/22 and documentation of a discharge should have been included in the record. OT #5 stated communication with Patient #5's care team was in the agency's internal communication tigertext; however, this was not documented within the patient record. 3. The clinical record for Patient #7 was reviewed on 4/12/22. Review of the plan of care for the certification period dated 12/14/21 to 2/11/22 revealed a SOC of 12/14/21; diagnoses included ischemic cardiomyopathy exacerbation, athrolsclerotic heart heart disaese (ASHD), other specific depressive episodes, type 2 diabetes mellitus without complications, and contusion of the right knee. Plan of care orders included; SN once weekly to assess and evaluate wound V.A.C. (vacuum assisted closure) dressing change, PT had no duration or frequency listed to assess, evaluate and treat; and OT had no duration or frequency listed to assess, evaluate and treat. a. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, the PT, OT and RN involved in Patient #7's care failed to ensure communication with each other to meet the patient's needs. Review of the plan of care, with start of care date 12/14/21 for the certification period of 12/14/21 to 2/11/22, not signed by a physician within the certification period, revealed a need for SN services one time a week and PT and OT to assess, evaluate and treat. The OT evaluation completed on 12/16/21 indicated a need for OT services; however, failed to reveal a frequency or duration of OT services. The PT evaluation completed on 1/6/22 indicated a need for PT services two times a week for four weeks. Review of the visit record between 12/14/21 to 4/11/22 revealed RN #4 completed the SOC on 12/14/21 and one other SN visit on 12/22/21, with no other SN visits, RN #4 had completed a discharge order request for Patient #7 due to placement in long term care on 2/16/22. OT #5 completed an evaluation on 12/16/21 and a visit on 12/23/21, with no other OT visits; and PT #3 had completed an evaluation on 1/6/22 and a visit on 1/11/22, with no other PT visits. The record failed to reveal documentation to explain why services were not provided in accordance with the plan of care or if the patient and all disciplines on the agency's care team had been in communication regarding patient care needs. During an interview on 4/12/22 at 8:48 a.m., OT #5 stated they had not remembered Patient #7 well and would need to refer to internal agency communication on tigertext. OT #5 confirmed documentation of communication between patient and other disciplines were not included in the patient record. During an interview on 4/12/22 at 12:34 p.m., PT #3 stated they could not speak to PT service lapse between SOC and 1/6/22; however review of the record failed to reveal a justification for the lapse in PT services and PT #3 had completed PT SOC on 12/14/21. PT #3 stated only two visits had been provided to Patient #7 as they had declined services ongoing and went back to work; however, this documentation was not within PT visit notes or elsewhere in the patient record. A second interview with PT #3 for additional clarification was attempted on 4/13/22 at 11:09 a.m. without a response. During an interview on 4/13/22 at 2:07 p.m., RN #4 stated Patient #7 was hospitalized at the end of December 2021 and later admitted to a skilled nursing facility for long term care. Additionally, RN #4 stated PT #3 could not have completed visits on 1/6/22 and 1/11/22 to Patient #7 due to Patient #7's inpatient status. The record failed to reveal documentation of communication regarding the missed visits, discharge or other communication with either the patient or the other agency disciplines involved. During an interview on 4/12/22 at 11:45 a.m., the DON attempted to review the agency's internal communication via tigertext; however, the communication had been archived; therefore, all documentation of Patient #7's care coordination between disciplines was not available for review. The DON confirmed all communication regarding patient care must be maintained within the patient record for continuity of care. 4. The clinical record for Patient #3 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/8/22 to 4/8/22 revealed a SOC date of 2/8/22; diagnoses included essential hypertension, type 2 diabetes mellitus without complications and COVID-19. Plan of care orders included; PT two times a week for four weeks for decreased functional mobility. a. The agency failed to ensure coordination in care delivery met the patient's needs, and involved the patient and caregivers.. Specifically, PT failed to ensure PT services ongoing were provided and changes to care were communicated with the patient. Review of the record revealed PT #3 completed a PT evaluation on 2/9/22 and scheduled visits between 2/11/22 to 3/7/22 were documented as declined by the patient. PT #13 completed missed visit documentation and notified the physician. However, services were not documented as having been attempted following 3/7/22. Review of the record between 3/7/22 to 4/11/22 failed to reveal an explanation as to why services were not provided or that the patient had been aware of the change to the plan of care. During an interview on 4/12/22 at 12:37 p.m., PT #3 stated they were the primary PT for the agency and had difficulty coordinating all patient care due to staffing concerns at the agency and had not followed up on any PT assistance services provided by PT #13 or need for discharge from PT services. PT #3 confirmed they had only completed a PT evaluation on 2/9/22 and not a discharge. During an interview on 4/12/22 at 1:45 p.m., the administrator reviewed the record and confirmed there was no documentation PT #13 or PT #3 had communicated with the patient about any revision to the plan of care following 3/7/22 and a discipline specific discharge had not been completed. 5. The clinical record for Patient #4 was reviewed on 4/11/22. Review of the plan of care for the certification period dated 2/1/22 to 4/1/22 revealed a SOC date of 2/1/22; diagnoses included heart failure, difficulty in walking. Plan of care orders included PT two times per week for four weeks to provide therapeutic exercises, therapeutic activities, neuro re-education and gait and transfer training and OT one time a week for two weeks, two times a week for two weeks to evaluate, establish and teach home exercise program, independent living training, teach ADLs and provide therapeutic exercise. a. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, the PT failed to ensure ongoing PT services were provided to the patient and changes to care were communicated with the patient and the OT discipline involved. Review of the record between 2/1/22 to 4/11/22 revealed PT #3 had completed an evaluation for SOC on 2/1/22 and an order request for an OT evaluation was sent to the physician on 2/1/22, however this had not been returned. Following SOC, services were not provided until PT #3 completed a routine visit on 2/17/22. The record failed to reveal documentation to explain why services were not provided between 2/2/22 to 2/16/22, if PT#3 had discussion regarding services with OT, or if the agency had communicated with Patient #4. Review of the completed visit notes revealed PT #3 provided services on four visits in total, dated: 2/17/22, 2/22/22, 2/24/22 and 2/28/22. The record revealed on 2/28/22 an order request to continue PT and OT services had been completed; however this order request had not been returned with physician signature. Following 2/28/22, the record failed to reveal documentation to explain why PT services were no longer provided or that Patient #4 had been made aware of changes to the plan of care. Additionally, the record failed to reveal communication that PT #3 had discussed ongoing therapy needs with OT #7 prior to OT #7 completing an agency discharge on 3/14/22. During an interview on 4/12/22 at 12:25 p.m., PT #3 stated they had completed the SOC assessment on 2/1/22; however, believed another PT was to complete the patient care ongoing. Therefore, PT#3 had not followed up on Patient #4's care. On 2/17/22, PT #3 began providing PT services to Patient #4 ongoing. PT #3 stated services were not provided after 2/28/22 due to staffing concerns and the agency was unable to meet the needs of Patient #4 at the time. Further, PT #3 stated they had not followed up on the order requests or services to be provided for PT and OT which stated ongoing rehab services were necessary and a member of office management had been tracking returned order requests for patient services. b. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, OT failed to ensure all therapy goals were met prior to completing discharge from the agency. Review of the OT discipline specific record revealed OT #7 had completed an OT evaluation on 2/18/22; two weeks following the order request for OT evaluation following the PT's SOC evaluation. The record revealed on 2/28/22 an order request to continue PT and OT services had been completed; however this order request had not been returned with physician signature. OT #7 had completed a discharge evaluation from the agency on 3/14/22; which had maintained a physician signature. The record failed to reveal OT #7 had been in communication with the PT to confirm PT goals were met and discharge of Patient #4 from the agency was appropriate for all disciplines on the patient care team. During an interview on 4/13/22 at 10:30 a.m., OT #7 stated order requests were sent to the physicians after being written by OT, however OT #7 had not tracked that the order requests were received or returned by physicians and that a member of the office management had been tracking this. Further, OT #7 stated OT services were not requested to be evaluated until 2/18/22; however, documentation showed the evaluation had been ordered on the SOC date of 2/1/22. OT #7 was not able to state a reason for this discrepancy. Regarding discharge, OT #7 stated insurance authorization for OT had ended and therefore Patient #4 was discharged from the agency. OT #7 completed the discharge from the agency, which they stated typically the PT completes; however, OT #7 was the only discipline in the home at the time of discharge regardless of order request for ongoing services completed on 2/28/22. During an interview on 4/13/22 at 4:13 p.m., the DON stated there was not a member of the office management who had been tracking order requests that were received by physicians. 6. The clinical record for Patient #6 was reviewed on 4/12/22. Review of the plan of care for the certification period dated 1/27/22 to 3/27/22 revealed a SOC date of 1/31/22; diagnoses included acute postprocedural pain, intervertebral disc displacement, lumbar region, type 2 diabetes mellitus without complications and essential hypertension. Plan of care orders included; PT two times per week for four weeks to establish and teach home exercise program, therapeutic exercise, transfer, gait and balance training and to teach fall safety and body mechanic precautions. a. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, PT failed to ensure communication with the patient and caregiver regarding a delay in services. Review of the clinical record revealed a plan of care dated 1/31/22 for the certification period dated 1/27/22 to 3/27/22, not signed by the physician or clinician, indicated the need for skilled PT services two times a week for four weeks, to include therapeutic exercises, therapeutic activities, neuro re-education, gait and transfer training. Review of the record between 1/31/22 to 4/11/22 revealed after SOC on 1/31/22, PT services were not provided until 2/23/22 by PT #3. There was no documentation of a reason why or that Patient #6 had been made aware of a change to the plan of care. During an interview on 4/12/22 at 12:30 p.m., PT #3 stated Patient #6 had refused PT due to pain following SOC until 2/23/22 when Patient #6 had requested PT services resume. PT #3 reviewed the record and confirmed this communication with Patient #6 or caregiver had not been documented within the patient record. During an interview on 4/12/22 at 2:30pm, the administrator stated they believed there had been a delay in services related to a pending insurance authorization. The administrator confirmed the reason for services to be delayed after SOC were not included in the patient record and therefore could not be confirmed. Additionally; internal agency communication on tigertext had been archived by this time and could not be referenced for review of any internal communication among the agency staff. During an interview on 4/14/22 at 7:30 a.m., Patient #6's caregiver stated PT services had not begun until 2/23/22 due to difficulties in communication between the agency, physician and insurance for authorization. Patient #6's caregiver stated the agency had not had a working fax machine to receive necessary documentation for several weeks in February 2022 and patient care had not been delayed due to the patient's pain levels contrary to PT #3's statement. 7. The clinical record for Patient #8 was reviewed on 4/13/22. Review of the plan of care for the certification period dated 3/4/22 to 5/2/22 revealed a SOC of 3/4/22; diagnoses included; nondisplaced intertrochanteric fracture of the left femur, encounter for surgical aftercare following surgery on the nervous system, memory deficit following cerebral infarction, other signs and symptoms of cognitive functions following a cerebral infarction, dysphagia following cerebral infarction, hypertensive heart disease. Plan of care orders included; PT one time for one week then two times a week for three weeks, to provide treatment to include therapeutic exercises, therapeutic activities, neuro re-education, gait training and transfer training and OT had no frequency or duration only to assess, evaluate and treat. a. The agency failed to ensure coordination in care delivery met the patient's needs and involved the patient and caregivers. Specifically, PT and OT disciplines providing services failed to ensure communication with each other to ensure patient's care needs were met. Review of the clinical record revealed a plan of care dated 3/4/22 for the certification period dated 3/4/22 to 5/2/22, not signed by the physician, indicated the need for skilled PT once for one week then twice a week for three weeks and OT services to assess, evaluate and treat. Review of the record further revealed OT services were discharged on 3/16/22 due to goals being met after one evaluation on 3/9/22, which had indicated a need for OT services one time a week for one week and then two times a week for four weeks. Review of the record revealed PT #3 had completed a routine visit on 3/9/22 and 3/11/22 only, with no ongoing visits after 3/11/22. The record failed to reveal documentation of communication with Patient #8 or with the OT discipline in the home regarding changes to the plan of care. An attempt to interview PT #3 had been made on 4/13/22 at 11:09 a.m. and at 3:03 p.m. without a response. During an interview on 4/13/22 at 2:57 p.m., OT #7 was asked if they had discussed with PT #3 the need for ongoing therapy in the home, OT #7 had not discussed with PT #3. OT #7 stated an OT discipline specific discharged was completed on 3/16/22; however, OT #7 believed PT services were still provided in the home. OT #7 had not been aware that Patient #8 had not received PT services since 3/11/22.