Every finding on record at Interstaff, Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 08/23/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 08/23/2023. The provider had 11 current patients.

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 policy review, record review, and interview, the home health provider failed to ensure a Registered Nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral in one of five records reviewed (Record/Patient #1). This deficient practice has the potential to affect identification of immediate care needs for all patients on service with the provider. Findings included: Review of the home health provider's policy titled, "Interdisciplinary Patient Assessments and Reassessments," last revised 01/12/2018, showed in part: -Skilled Nursing (SN) evaluates the patient in his/her place of residence, or hospital for appropriateness of the care treatment and /or services requested within 48 hours of the referral, or 48 hours of the return home, or on the physician- ordered start of care date; and -Physical Therapy (PT) performs the initial evaluation visit when the physician has ordered only physical therapy services within 48 hours of the referral, or 48 hours of the return home, or on the physician- ordered start of care (SOC) date. RECORD/PATIENT #1: Review of the clinical record showed: A physician's order dated 07/27/2023 for physical therapy (PT) and occupational therapy (OT) due to recent hospitalization. A patient medical records referral facsimile from a local hospital dated 07/29/2023, with a discharge date of 07/29/2023 for the patient. Review of the document titled "Comprehensive Adult Nursing Assessment," showed the patient was admitted on 08/01/2023, 72 hours after hospital discharge. During an interview on 08/23/2023 at 1:00 PM, the alternate administrator stated that patients should be assessed within the first 48 hours of the referral and the patient’s SOC.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the provider failed to complete a review of all of the medications the patient was taking in one of three home visits completed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Completion of the Comprehensive Assessment (OASIS)," dated 01/12/2018, showed the patient's current medications, both prescribed and over-the-counter, including herbal remedies, based on current knowledge for actions, drug-to-drug and drug-to-food interactions, dosage appropriateness of administration routes, and medication effectiveness should be assessed and documented in the record. RECORD/PATIENT #1: Observation and interview on 8/22/2023 at 11:30 AM, during the patient's home visit, showed the patient had the following medication discrepancies: -The provider's medication profile showed the patient was taking Loratadine (used to relieve allergies) 10 milligrams (mg) 1 tablet by mouth daily. The patient's caregiver stated that the patient was not taking this medication; -The provider's medication profile showed the patient was taking Acetaminophen (used to treat minor aches and pains) 325 mg 2 tablets by mouth every 4-6 hours as needed for pain/fever. The patient's caregiver stated that the patient was not taking this medication; -The following medications were missing from the provider's medication profile; * Atorvastatin (used to treat high cholesterol) 20 mg daily at bedtime; * Lisinopril (used to treat high blood pressure) 10 mg daily; and * Aspirin (used to treat pain, fever, headache, and inflammation) 81 mg daily. During an interview on 08/22/2023 at 12:00 PM, the home health alternate administrator stated that he/she would expect the medications to match between the provider's medication profile and what the patient had in the home.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure the patient received home health services as ordered by the physician and written in an individualized plan of care, in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential for unmet needs for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Care Plan Implementation,” (C-10024) dated revised 01/29/2021, showed the following: - Purpose: To ensure that “Named provider” provides care, treatment and/or services for each patient according to the established plan of care for treatment and/or services; and - This HHA (home health agency) shall provide care, treatment and/or services consistent with the type and frequency identified and documented in the plan of care and on the days and at the times scheduled with the patient/family. RECORD/PATIENT #5: Review of the clinical record showed: - A POC (plan of care) dated 04/03/2023 to 06/01/2023 with orders for OT (occupational therapy) to eval (evaluate) and treat week of 04/02/2023; and - The clinical record failed to contain documentation of an OT evaluation. During an interview on 08/23/2023 at 2:07 PM, the alternate administrator stated that: - I didn’t take it (the order for OT evaluation) off when the patient refused; and - That would be a clerical error; and - OT should not be on that POC at all.

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 policy review, record review, and interview, the home health provider failed to include all patient care orders on the plan of care in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the care provided to all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” (C-10022), dated revised 01/29/2021, showed in part: - The Registered Nurse and/or Licensed Therapist develops a plan of care within 24 hours of the start of care; - The plan of care covers all patient care orders, including verbal orders; - The plan of care is reviewed, updated and/or modified at least every two (2) weeks, and more often if necessary; - The total plan of care shall be reviewed by the attending physician and HHA (home health agency) staff as often as the severity of the patient’s condition requires, but at least once every sixty (60) days; and - Any reviews of, and/or changes to, the plan of care are dated and signed by the appropriate discipline whenever it is reviewed, whether or not there are changes to the plan of care. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 07/22/2022 with a principal diagnosis of lymphedema of lower extremities (swelling caused by lymphatic system blockage). He/she also had other pertinent diagnoses of chronic diastolic congestive heart failure (a condition where the left ventricle of the heart is not able to fill properly with blood during the diastolic phase (relaxation phase of the heartbeat), reducing the amount of blood pumped out to the body), hypertension (high blood pressure), and atherosclerotic heart disease of native coronary artery without angina pectoris (also called coronary artery disease- damage or disease in the heart’s major blood vessels causing coronary arteries to narrow, limiting blood flow to the heart without resulting chest pain); - A physician’s order dated 07/13/2023: Recertification to be completed on 07/13/2023, continue all previous orders, and agency parameters ok for MD (medical doctor) notification except notify MD if HR (heart rate) - A plan of care dated 07/22/2023 to 09/14/2023 which failed to include to notify MD if HR During an interview on 08/23/2024 at 1:57 PM, the alternate administrator stated that: - The order should be on the plan of care dated 07/22/2023 to 09/14/2023; and - It (the plan of care) was not updated appropriately.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, observation, and interview, the home health provider failed to ensure the medication schedule/instructions were placed in the patient's home in one of three home visits conducted (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Patient's Home Chart," dated 01/12/2023, showed the home charts should always include any information pertaining to the patient's care, services to be received, anticipated discharge notices, and consent forms required for the patients specific care. RECORD/PATIENT #1: Observation on 08/22/2023 at 12:00 PM, during the patient's home visit, showed the patient's home binder failed to contain a medication profile that listed the patient's current medications. During an interview on 08/22/2023 at 12:00 PM, the patient's caregiver stated that he/she does not have a written list of medications that the patient takes. During an interview on 08/23/2023 at 1:00 PM, the alternate administrator stated that he/she would expect there to be a written medication list in the patient's home.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the home folder contained a list of treatments to be administered by home health personnel in one of three home visits conducted (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Patient's Home Chart," dated 01/12/2023, showed the home charts should always include any information pertaining to the patient's care, services to be received, anticipated discharge notices, and consent forms required for the patients specific care. RECORD/PATIENT #1: Review of the clinical record showed the patient was receiving PT services two times per week for strengthening. Observation on 08/22/2023 at 12:00 PM, during the patient's home visit, showed the patient's home binder failed to contain a list of the PT treatments the patient was receiving. During an interview on 08/22/2023 at 12:00 PM, the patient's caregiver stated that he/she does not have a written list of the treatments that the patient was receiving. During an interview on 08/23/2023 at 1:00 PM, the alternate administrator stated that he/she would expect there to be a written treatment list in the home.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation, and interview, the home health provider failed to follow accepted standards of practice in one of three home visits completed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Nursing Bag Technique," dated 01/29/2021, showed reusable equipment shall be cleaned using alcohol, antiseptic spray and/or soap and water as appropriate. RECORD/PATIENT #1: Observation on 08/22/2023 at 12:00 PM, during the patient's home visit showed physical therapist (PT) A did the following: -Removed a cloth gait belt from his/her bag; -Placed the gait belt on the patient; -Walked with the patient out to the curb in front of the house and back; -Removed the cloth gait belt from the patient; and -Placed the gait belt back in his/her bag without cleaning the gait belt. During an interview on 08/23/2023 at 1:00 PM, the home health alternate administrator stated that he/she would expect the gait belt to have been cleansed after use with the patient prior to placing it back into his/her bag or each patient should get his/her own gait belt.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure all entries into the medical record were legible, clear, and complete in, but not limited to, one of five full record reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy numbered, "C-10117," showed submission of skilled visit notes must be legible. RECORD/PATIENT #1: Review of the clinical record showed patient was admitted to home health on 08/01/2023 with orders for physical therapy (PT) services. Review of the physical therapy visit notes with dates ranging from 08/03/2023 - 08/17/2023 showed illegible handwriting within each of the visit notes. During an interview on 08/23/2023 at 1:00 PM, the alternate administrator stated that he/she has received a few notes regarding the illegible handwriting prior to interview and will reeducate staff regarding documentation options.

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), §485.625(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, "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 employee file review and interview, the agency failed to ensure staff were provided emergency preparedness training during orientation for three (EMPLOYEE #1, #2, and #3) of three employee records reviewed. This deficient practice has the potential to affect emergency preparedness practices for all agency staff. Findings included: EMPLOYEE #1 (E1): Review of E1's employee file showed: - Registered Nurse (RN); - Date of hire 07/30/2020; and - No documentation of emergency preparedness training during orientation or at the time of the current survey. EMPLOYEE #2 (E2): Review of E2's employee file showed: - Contracted Occupational Therapist (OT); - Date of hire 01/13/2020; and - No documentation of emergency preparedness training during orientation or at the time of the current survey. EMPLOYEE #3 (E3): Review of E2's employee file showed: - RN; - Date of hire 08/12/2019; and - No documentation of emergency preparedness training during orientation or at the time of the current survey. During an interview on 01/13/2021 at 11:30 AM the director of nursing stated: - He/She was unable to show all employees were in-serviced on emergency preparedness; and - He/She tried to monitor that staff did the required in-services but due to Covid-19, he/she had not had time to do this.

A partial extended survey for Medicare certification for Interstaff, INC was completed on 1/13/2021 with standard level deficiencies cited. The agency had 32 current patients. A COVID-19 Focused Infection Control survey was completed in conjunction with the survey and three deficiencies were identified related to the Focused Infection Control survey. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey completed on 01/13/2021. One standard level deficiency was identified.

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- ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in two (Patient/Record #1 and #3) of five records reviewed. This deficient practice has the potential to affect the immediate needs of all the agency's patients. Findings included: RECORD/PATIENT #1: Review of the "Care Summary for Including OASIS (assessment tool) Elements for Transfer to Inpatient Facility" form dated 12/29/2020 and signed by the physical therapist (PT) showed the patient was admitted to the hospital on 12/28/2020. Review of a PT "Case Conference Patient Report" dated 01/01/2021 showed: - The PT recorded the patient's caregiver called the PT cell phone and stated the patient was home from the hospital; - The PT explained that new orders were needed to resume home care; and - The PT spoke with the Registered Nurse (RN) C on call regarding information that the patient had returned home. During an interview on 01/13/2021, the director of nursing (DON) stated: - He/she was on vacation the week the patient was discharged home from the hospital and did not know he/she had been in the hospital until 01/06/2021; - RN C was on call and was notified by the PT that the patient returned home; - RN C did not make any arrangements to readmit the patient and the DON did not know why; - The DON found out the patient was home on 01/06/2021, readmitted the patient and attempted to obtain orders from the physician, eight days after the patient returned home; - He/she sent the resumption of care (ROC) plan of care to the physician's office and called several times to get orders from the physician but the physician had not contacted or sent orders as of 01/13/2021; and - He/she said if orders were not received timely, he/she would go and sit in the physician's office until orders were given. RECORD/PATIENT #3: Review of the clinical record showed: - The agency's client referral form dated 12/19/2020 showed a referral date of 12/18/2020; - Review of a Physician's order dated 12/17/2020 showed an order for skilled nursing for wound care; - The admission nursing assessment dated 12/21/2020 showed the date of the physician ordered start of care was blank, the date of referral was documented as 12/18/2020; and - The agency did not start the patient's care until 12/21/2020 (three days after the physician's referral). During an interview on 01/13/2021 at 10:31 AM, the Director of Nursing (DON) said the start of care should be within 48 hours of the patient's referral.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure an accurate medication review and/or update of the patient's medications was completed in two (Records/Patients #1 and #3) of three home visit observations performed. This deficient practice has the potential to affect the agency's ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Orders and Administration," dated 01/12/2018 showed: - Purpose: To promote the integrity of medication management when patients are receiving care, treatment, and/or services from the agency; - When a patient returns to the agency following hospitalization, all medication orders must be written in detail; - All medication orders, whether written by the agency staff or by the ordering physician, should be reviewed by the case manager/clinical supervisor to ensure that the orders are complete, legible, and clear. Correct and complete orders shall be initialed by the case manager/clinical supervisor; and - All medication orders must be verified with the ordering physician and must contain the phrase "Orders read back and verified with __________ ", the date of verification, and signature of the nurse verifying the orders. Review of the agency's policy titled, "Medication Monitoring," dated 01/12/2018 showed: - The skilled nurse/therapist monitors the patient's response to medications at least once a week, and more frequently if needed, based on the patient's clinical needs and/or response to care, treatment, and/or services; - The monitoring process includes at least reviewing and evaluating the medication profile; and - The findings, conclusions, and recommendations of medication monitoring are communicated with the physician. RECORD/PATIENT #1: Review of the resumption of care (ROC) POC (plan of care) dated 01/06/2021 for the certification period of 12/15/2020 through 02/12/2021 showed: - SOC date 12/15/2020 and ROC date 01/06/2021; and - Diagnoses included but not limited to: Pain in left leg, colostomy (a surgical procedure that creates an opening for the colon, or large intestine, through the abdominal wall for the excretion of fecal material), hypersensitivity angitis (an inflammation of the blood vessels), aseptic necrosis of the humerus (decreased blood supply to humeral (upper arm bone) head leading to death of cells in bony matrix), Stage 5 chronic kidney disease (the final stage of chronic kidney disease), end stage renal disease (kidneys no longer function and dialysis is needed), polyneuropathy (damage to the peripheral nerves, and signs may include a prickling, burning, or numb sensation), sleep apnea, major depressive disorder, hypothyroidism (occurs when your body doesn't produce enough thyroid hormones), long term use of anticoagulants (blood thinners), dependence upon dialysis (a treatment that filters and purifies the blood using a machine; helps keep fluids and electrolytes in balance when the kidneys fail), and wheelchair dependence. Review of the agency's current medication profile report dated 01/12/2021 showed: - Percocet (Oxycodone, a narcotic pain reliever) 5/325 milligrams (mg) one twice daily (BID) as needed (PRN); - Warfarin (blood thinner) 7.5 mg daily; - Olanzapine (for manic depression) 5 mg daily; - Mirtazapine (for depression) 30 mg daily; - Tizanadine (for muscle spasms) 4 mg BID; - Duloxetine (for anxiety and depression) 30 mg daily; - Trazadone (for depression) 100 mg at bedtime (HS); - Levothyroxine (for hypothyroidism) 25 micrograms (mcg) daily on an empty stomach; - Nitroglycerin (NTG) (for chest pain) 0.4 mg under the tongue every five minutes for chest pain, call 911 if no relief of pain; - Lisinopril (for high blood pressure) 40 mg daily; - Loperamide (for diarrhea) 2 mg, one capsule after every episode of diarrhea, as needed (PRN); - Nicotine patch (for smoking cessation) 21 mg patch daily; - Ventolin inhaler (for shortness of breath, asthma, COPD) 90 mcg, two puffs BID; - Escitalopram (for depression) 10 mg daily; - Amlodipine (for high blood pressure) 10 mg daily; - Carvedilol (for high blood pressure and heart failure) 25 mg BID; - Hydralazine (for high blood pressure) 50 mg three times per day (TID); - Renal Cap (a supplement) one TID with food; - Pantoprazole (for reflux disease) 40 mg daily; - Ascorbic acid (Vitamin C supplement) 500 mg daily; - Vitamin B complex (supplement) one daily; - Oxycodone IR (immediate release, Percocet) 5 mg one every 12 hours PRN (as needed); - Menthol-Camphor (topical for pain relief) BID to the affected area; - Ondansetron (for nausea) 4 mg every eight hours PRN; - Gabapentin (neuropathy pain) 300 mg BID; - Melatonin (for sleep) 3 mg at HS; - Prednisone (an anti-inflammatory medication) 10 mg daily; - Renvela (to lower phosphorus levels due to severe kidney disease) 800 mg TID with food; and - Voltaren Gel (for pain) topically TID to affected areas PRN. During a home visit observation on 01/12/2021 at 12:20 PM, review of the patient's bottles of medications and interview with the patient and caregiver showed: - The patient stated he/she did not take Percocet (Oxycodone) 5/325 mg BID PRN; - He/she took Oxycodone IR (Percocet) 5 mg every 12 hours PRN; - He/she did not take Nitroglycerin tablets for chest pain; - He/she did not take Hydralazine; - He/she did not use Menthol-Camphor for pain; - He/she said the Gabapentin was change to three times per week but he/she takes it TID; - He/she took the Renal Cap one daily; - He/she took Tizanadine 4 mg one every eight hours; - He/she took Nephrovite (an iron supplement) 0.8 mg daily on dialysis days; - He/she took Cinacalacet HCL (used to treat increased amounts of a certain hormone (parathyroid) in people with long-term kidney disease who are on dialysis) 60 mg one with the evening meal; - The care giver said the patient took Alprazolam (used for anxiety and panic disorders) 1 mg TID; - The caregiver said the Hydralazine was stopped in the hospital; - The caregiver said the patient did not take the Vitamin B complex; - The caregiver said the patient did not take Melatonin; - The caregiver said the patient took Benadryl 25 mg, three tablets before each dialysis treatment; - The caregiver said the patient did not use the Nicotine patches because they were too expensive; and - The caregiver said he/she tried many times to contact the physician about new and changed medications but the physician did not respond to him/her. During an interview on 01/12/2021 at 12:45 PM, the director of nurses (DON) stated: - He/she did the ROC on 01/06/2021 and did not get discharge orders until four days later; - Updates for medication changes not on POC and the medication sheet in the home needed to be updated; - He/she instructed the patient to continue to take the Alprazolam as directed; - He/she did not understand why they changed the Gabapentin from TID to three times per week; - He/she said the patient verified that he/she took the Gabapentin TID not three times per week; - He/she made many attempts to get orders from the physician, but the physician did not respond to the nurse or the caregiver; and - He/she strongly recommended that the caregiver call for an appointment with the physician to discuss medications and changes in medications. RECORD/PATIENT #3: Review of the plan of care (POC) dated 12/21/2020 through 02/18/2021 showed: - The start of care (SOC) date was 12/21/2020; and - Diagnoses included but not limited to: Venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), non-pressure chronic ulcer of other part of right and left lower leg with fat layer exposed, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, chronic obstructive pulmonary disease (COPD) with exacerbation (acute increase in the severity of a illness), long term use of insulin and oral hypoglycemic (drugs used only in the treatment of type 2 diabetes which is a disorder involving resistance to secrete insulin) drugs. Review of the agency's patient medication profile report dated 12/21/2020 showed: - Advair (bronchodilator): 250-50 micrograms (mcg), one puff twice daily for COPD; - Gabapentin (anticonvulsant and nerve pain medication) 300 milligrams (mg) by mouth daily for neuropathy; - Glimepiride (anti-diabetic medication) 4 mg daily before breakfast for diabetes mellitus (DM) (too much sugar in the blood); and - Tramadol (treats moderate to severe pain) 50 mg every six hours as needed. During a home visit observation on 01/12/2021 at 10:50 AM, review of the patient's bottles of medications and interview with the patient showed: - Gabapentin 300 mg three times a day; - Losartan potassium 25 mg twice a day; - Losartan Potassium was not included in the agency list of medications; - Magnesium oxide 40 mg one tablet every day; - Magnesium oxide was not included in the agency list of medications; - Symbicort 160/4.5 mg two puffs twice a day; - Symbicort was not included in the agency list of medications; and - Tramadol 50 mg twice a day; - The patient stated he/she takes Gabapentin three times a day but sometimes takes it twice a day; - Stated he/she takes glimepiride but not every day because it "makes him/her drowsy and dizzy"; - Stated he/she takes losartan potassium (treats high blood pressure) 25 mg twice a day; - Stated he/she no longer used Advair and takes Symbicort (bronchodilator) instead; and - Stated the prescription for Tramadol was twice daily but he/she hasn't taken the medication for weeks because it "makes him/her dizzy". During an interview on 01/13/2021 at 9:19 AM, registered nurse (RN) A stated: - He/she asks to see the patient's medications and reviews them during visits; - The patient says he/she is not taking any more medications but "picks and chooses" what medications he/she is going to take; - If the patient feels dizzy he/she won't take the medication; and - He/she would have documented if the physician was notified of the medication discrepancies. Review of the patient's medical record on 11/13/2021 at 11:00 AM failed to include any orders to confirm the changes in medications that were reported by the patient. During an interview on 01/13/2021 at 10:31 AM, Director of Nursing (DON) stated: - When reconciling medications staff usually call the physician; - The nurse reviews the medication list and if there are discrepancies they contact the pharmacy; and - There was no further documentation regarding the medication discrepancies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide each patient with an individualized plan of care that was established by the physician in, but not limited to, one (Record/Patient #4) of five records reviewed. This deficient practice has the potential to impact the care provided to all agency patients. Finding included: Review of the agency's policy titled, "Care Planning," revised 01/12/2018 showed, in part, all clinical services shall be implemented only in accordance with a plan of care established by a physician's written orders. Review of the agency's policy titled, "HHA (home health agency) Care Plan Implementation," revised 01/12/2018 showed: - Purpose: To ensure the HHA provides care, treatment and/or services for each patient according to the established plan of care for treatment and/or services; - Policy: This HHA shall provide care, treatment and/or services consistent with the type and frequency identified and documented in the plan of care; - For each patient according to accepted professional standards and applicable laws and regulations; and - Processes utilized by the HHA to validate that consistent care, treatment and services are delivered within the scope of practice of HHA staff and in accordance with clinical guidelines. RECORD/PATIENT #4: Review of the plan of care (POC), dated 10/14/2020 through 12/12/2020, showed: - The patient was admitted to home health services on 10/14/2020; - Diagnoses included paraplegia, osteoarthritis, repeated falls and hypertension; - Call physician for the following: blood pressure systolic (indicated how much pressure blood is exerting against artery walls when the heart beats) greater than 160 or diastolic (amount of pressure in arteries between heart beats) greater than 90; - Occupational Therapy (OT) 1w1 (1 times per week for 1 week), 2w8 (2 times per week for 8 weeks); and - Home health aide 3w4 (3 times per week for 4 weeks) effective 10/18/2020 to provide personal care and assist with activities of daily living per aide care plan developed by skilled nursing. Review of the clinical record showed: - OT completed their initial evaluation 10/28/2020 (14 days after the physician's order); - The home health aide care plan, dated 10/14/2020 showed instructions to notify the registered nurse (RN) if the patient's blood pressure was greater than 160/96 (the physician's ordered plan of care showed to notify the physician if the blood pressure was greater than 160/90); - Review of the home health aide visit notes showed the patient's blood pressure was 158/98 on 10/30/2020, 151/91 on 11/02/2020, 137/93 on 11/06/2020, 139/95 on 11/13/2020, and 139/95 on 11/16/2020. The physician orders were to notify the physician of diastolic higher than 90; and - The home health aide made additional visits to the patient on 11/16/2020, 11/18/2020, 11/20/20 and 11/23/2020 without orders. During an interview on 01/13/2021 at 10:31 AM and 10:54 AM, the director of nursing (DON) said: - The patient's blood pressure parameters on the home health plan of care should have been the parameters on the physician's plan of care because the patient had issues with his/her blood pressure and the RN and physician should have been notified of the patient's diastolic above 90; - OT generally takes a while to assess the patient due to scheduling conflicts; - He/she has met one on one with the therapy agency regarding issues with OT's late start of care and the issue does not get resolved; and - The home health aide made visits without physician orders and he/she spoke to the home health aide about watching frequency of visits.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, and interviews, the agency failed to ensure each patient received written information related to visit schedule/instructions in two of three applicable cases (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients admitted to the home health agency. Findings included: RECORD/PATIENT #1: Review of the patient's resumption of care (ROC) plan of care dated 01/06/2021 for the certification period of 12/15/2020 through 02/12/2021 showed: - Diagnoses included but not limited to: Pain left leg and colostomy (a surgical procedure that creates an opening for the colon, or large intestine, through the abdominal wall for the excretion of fecal material); - Skilled nurse to visit 1w1 (one visit for one week), 2w3 (two visits per week for three weeks), and PRN (as needed for a change in condition); and - Physical therapy (PT) evaluate week of 12/15/2020 and call the physician for further orders; and - Home health aide 1w1, 3w4 (three visits per week for four weeks), to provide personal care and assist with activities of daily living (ADLs). During a home visit observation on 01/12/2021 at 12:20 PM, the information provided to the patient by the home health agency was reviewed. The information provided failed to include a schedule of the skilled nurse visits and the home health aide visits. The agency failed to ensure the patient received written information related to the visit schedule, including frequency of visits for the skilled nurse and home health aide visits. During an interview on 01/12/2021 at 12:45 PM, the director of nursing (DON) stated: - There was no schedule in the home packet of information for skilled nurse or home health aide visits; - Only the PT visits were recorded on the calendar; and - All disciplines should keep the calendar updated. RECORD/PATIENT #3: Review of the plan of care (POC) dated 12/21/2020 through 02/18/2021, showed skilled nursing to check vital signs, blood sugars and medication regimen 2w4 (2 times a week for 4 weeks). During the home visit observation on 01/12/2021 at 10:50 AM, the information provided to the patient by the home health agency was reviewed. The information provided failed to include a schedule of the skilled nurse visits. The agency failed to ensure the patient received written information related to the visit schedule, including frequency of visits for skilled nursing service. During an interview on 01/12/2021 at 5:30 PM, the patient stated he/she was not sure if staff leave a written schedule of visits but they call before they come. During an interview on 01/13/2020 at 10:31 AM, the DON stated a blank calendar is in every patient's home packet for staff to keep updated with visit schedule.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, record review, observation, and interviews, the agency failed to ensure staff followed infection control standards of practice in two (Record/Patient #1 and #2) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Standard Precautions Pertaining to Open Areas (Wounds)," dated 01/12/2018 showed: - Purpose: To prevent the transmission of infectious agents associated with healthcare delivery; - Gloves to be worn when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and other contaminated items; and - Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Review of the agency's policy titled, "Hand Hygiene-CDC (Center for Disease Control) Guidelines," dated 01/12/2018 showed: - Purpose: To provide guidelines for effective hand hygiene in order to prevent the transmission of bacteria, germs, and infection; - Change gloves when moving from one contaminated body site to a clean body site on the same patient; and - The CDC recommended use of either a non-bacterial soap and water, an antibacterial soap and water or an alcohol based hand sanitizer when hands are soiled, after coming in contact with a contaminated body site and moving to a clean body site, after coming in contact with bodily fluids and after removal of gloves. Review of the agency's policy titled, "Nursing Bag Techniques," dated 01/12/2018 showed: - Purpose: To maintain a clean nursing bag and prevent the transmission of infection to patients; - The bag shall not be placed down on the floor at a patient's home or in a patient room/care area; the bag shall be placed on a chair or table; - After cleansing hands with hand sanitizer, all clean supplies and equipment needed for the visit shall be removed from the bag; - At completion of the visit, contaminated supplies/equipment shall be contained/disposed of as necessary; - Reusable equipment shall be cleaned using alcohol, antiseptic spray and/or soap and water as appropriate; - Hands shall be cleansed prior to returning clean equipment and supplies to the bag; - Dispose of paper towels, newspapers used as a protective barrier for bag placement; and - Clean bag on a regular basis and as needed. RECORD/PATIENT #1: Review of the patient's resumption of care (ROC) plan of care dated 01/06/2021 during the certification period of 12/15/2020 through 02/12/2021, showed: - Skilled nurse 1w1 (one time a week for one week), 2w3 (two times a week for three weeks), and PRN (as needed) for changes in condition; - Diagnoses included but not limited to: Encounter for attention to colostomy (a surgical procedure that creates an opening for the colon, or large intestine, through the abdominal wall for the excretion of fecal material), and (self-inflicted wounds to the abdomen, not listed on current plan of care diagnoses); - Colostomy care with changing and application of ostomy pouch and skin assessment and care; and - Wound care to the self-inflicted open areas to the right upper quadrant (RUQ) of the abdomen and right lower quadrant (RLQ) of the abdomen per physician's order. Observation of colostomy care and wound care during a home visit on 01/12/2021 at 12:20 PM showed: - The director of nursing (DON and also a registered nurse) used hand sanitizer, put on gloves, removed the soiled colostomy bag and wiped the skin with 4x4 gauze sponge; - Removed gloves and did not use hand sanitizer or soap and water to wash hands; - Put on clean gloves, removed the small duoderm (a hydrocolloid, moisture-retentive wound dressing used for partial and full-thickness wounds with drainage) dressing from the RUQ abdominal wound, removed his/her phone from his/her pocket and placed the phone on the bedside table, reached into the bag of clean 4x4 gauze sponges, cleansed the wound with a 4x4 gauze sponge and wound cleanser, dried the area with a 4x4, opened a package of sterile cotton tip swabs, measured the wound, and applied a small duoderm dressing over the wound; - Used the same soiled gloves, reached into the bag of 4x4s, sprayed liquid skin barrier around the colostomy stoma and applied the ostomy bag; - Used same soiled gloves and removed the old duoderm dressing from the RLQ of the abdomen, cleansed the wound with wound cleanser and a 4x4 gauze sponge, measured the wound with a cotton tipped swab, placed a small duoderm dressing over the wound; - Instructed the patient to roll to his/her side, the DON pulled down the resident's pants and checked the coccyx area for open areas using the same soiled gloves, then applied a small piece of tape to the lower portion of the RLQ duoderm dressing; - Removed gloves and used hand sanitizer. During an interview on 01/13/2021 at 1:15 PM, the DON stated he/she did not realize he/she used the same soiled gloves to apply the clean ostomy bag and then performed wound care and other activities, but he/she should have changed his/her gloves and used hand sanitizer between dirty and clean tasks. RECORD/PATIENT #2: Review of the patient's initial plan of care dated 11/13/2020 through 01/12/2021 showed: - Skilled nurse visits 2w4 (two times a week for four weeks) and PRN for changes in condition; and - Diagnoses included but not limited to: Diabetes mellitus (high blood sugar levels), non-pressure chronic ulcer of the right foot, non-pressure chronic ulcers of the right lower leg, high blood pressure, and hemiplegia (paralysis of one side). During a home visit on 01/13/2021 at 11:25 AM, registered nurse (RN) A did the following: - Placed a clean barrier on the floor and placed his/her nursing bag on the barrier; - Used a clean barrier on the bed and placed the stethoscope, thermometer, oximeter (used to check oxygen level in the blood stream), blood pressure cuff, and scissors on the clean barrier after cleaning each one with a sanitizing wipe; - Used hand sanitizer, put on gloves and obtained the patient's blood pressure, pulse, respirations, temperature, and oxygen saturation level and placed the used equipment back down on the barrier; - At the end of the visit, RN A cleaned the blood pressure cuff, stethoscope, thermometer, oximeter and scissors with a sanitizing wipe, then placed the cleaned equipment back onto the soiled/used barrier and removed the blood pressure zip bag from the nursing bag, placed the cuff into the zip bag and then placed all the other equipment into his/her nursing bag. During an interview on 01/13/2021 at 12:45 PM, RN A stated: - He/she did not think about equipment not being placed on the soiled barrier after cleaning but he/she should have placed the equipment into the nursing bag after cleaning them; - He/she did not know what the agency policy required; - He/she cleaned the equipment before and after each patient use and cleaned his/her nursing bag every night because he/she had a child at home. During an interview on 01/13/2021 at 1:30 PM, the DON stated RN A should have placed the cleaned equipment directly into the nursing bag after cleaning and not on the soiled barrier.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee file review, and interview, the agency failed to ensure staff were provided infection control training during orientation and annually for two (Employee #1 and #3) of three employee files reviewed. This deficient practice has the potential to affect infection control practices of all agency staff. Findings included: Review of the agency's policy titled, "Infection Prevention and Control Program," dated 01/12/2018 showed: - Purpose: To reduce the risk of acquired or transmitted infections among home health agency patients and staff through a formalized, coordinated process to reduce those risks; and - Infection prevention and control in-service education shall be provided to all home health agency staff including contracted staff, during orientation and at least annually. EMPLOYEE #1 (E1): Review of E1's employee file showed: - Registered Nurse (RN); - Date of hire 07/30/2020; and - No documentation of infection control training during orientation in 2020 or at the time of the current survey in January, 2021. EMPLOYEE #3 (E3): Review of E3's employee file showed: - RN; - Date of hire 08/12/2019; and - No record of infection control training during orientation in 2019, annually for 2020, or at the time of the current survey in January, 2021. During an interview on 01/13/2021 at 11:30 AM, the director of nursing stated: - He/She was unable to show all employees were in-serviced on infection control training; and - He/She tried to monitor that staff did the required in-services but due to Covid-19, he/she had not had time to do this.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician; (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 policy review, record review, and interview, that agency failed to ensure that the home health aide/certified nurse's aide (CNA) provided services that were ordered by the physician, and included in the plan of care (POC) for one (Record/Patient #1) of three records with CNA services reviewed. This deficient practice has the potential for unmet needs for all agency patients served by the agency. Findings included: Review of the agency's policy titled, "Certified Home Health Aide Supervision," dated 01/12/2018 showed: - Purpose: To ensure personal care and services are provided in accordance with the best practices and meet the patient's needs and promote positive patient outcomes; - Supervision must ensure that aides furnish care in a safe and effective manner to include but not limited to following the patient's POC for completion of tasks assigned to the CNA by the registered nurse (RN) or other appropriately skilled professional. RECORD/PATIENT #1: Review of the initial POC dated 11/14/2020 through 02/12/2021 showed: - Start of care date 12/15/2020; - Diagnoses included but not limited to: Colostomy (a surgical procedure that creates an opening for the colon, or large intestine, through the abdominal wall for the excretion of fecal material), polyneuropathy neuropathy (damage to the peripheral nerves, and signs may include a prickling, burning, or numb sensation), end stage kidney disease, and anxiety; - CNA 1w1 (one time for one week), and 3w4 (three times per week for four weeks); and - Provide personal care and assist with activities of daily living (ADLs) per the CNA care plan developed by the skilled nurse (SN). Review of the "Home Health Aide/CNA Care Plan" dated 12/15/2020 showed: - Diagnoses: Colostomy, anxiety, depression, left lower extremity and right upper extremity pain and Good pastures Syndrome (a rare disorder in which your body mistakenly makes antibodies that attack the lungs and kidneys.) - Goals: Maintain optimum level of hygiene throughout the POC and patient and caregiver will be competent and safe with ADLs and performing personal care; - Vital signs (blood pressure, pulse, temperature, and respirations) every visit; - Complete bed bath, tub or shower as needed; - Shampoo, brush/comb hair, skin care, clean/file nails every visit; - Foot care and soak every visit; - Assist with dressing, transfers, and ambulation as needed; - Assist with range of motion (of extremities) and positioning patient every visit; - Question fluid intake and appetite every visit; - Colostomy care every visit; - Lives with family member and up as tolerated; - Prone to falls; - Bleeding, fall, cardiac, and psychiatric precautions and 24 hour supervision; and - Signed and dated by the director of nursing (DON) on 12/15/2020. Review of the clinical record showed no CNA visit notes or missed visit notes from 12/15/2020 through 12/28/2020 when the patient was admitted to the hospital. During an interview on 01/13/2021 at 2:00 PM, the DON stated: - No visit notes or missed visit notes from CNA B were found in the "to be filed stack" to be placed into the clinical record for the patient between 12/15/2020 through 12/28/202 when the patient was transferred to the hospital; - CNA B will be terminated because he/she never returned to work after he/she was assigned to care for the patient; - He/she made numerous phone calls to locate CNA B but CNA B never returned the calls; - He/she assumed that no visits were made to assist the patient as ordered and written in the CNA care plan; - He/she discovered this upon the surveyor's request for copies of the CNA visit notes during the agency's survey; - RN supervision of CNAs was waived due to Covid-19 and he/she did not make any supervisory visits; and - Since the patient's return home from the hospital on 12/29/2020, another CNA was assigned to the case and other services provided by Medicaid have been added.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure staff received Alzheimer's training during orientation for one (Employee #3) of three employee files reviewed. This deficient practice has the potential to affect all agency staff. Findings included: EMPLOYEE #3 (E3): Review of E3's employee file showed: - Registered Nurse (RN); - Date of hire 08/12/2019; and - No documentation of Alzheimer's training during orientation or at the time of the current survey process. During an interview on 01/13/2021 at 11:30 AM, the director of nursing stated: - He/She was unable to show all employees were in-serviced on trainings; and - He/She tried to monitor that staff did the required in-services but due to Covid-19, he/she had not had time to do this.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency/services within five business days of the patient's discharge in two (Record/Patient #4 and #5) of two discharge records reviewed; and failed to send a comprehensive transfer summary within two business days of the patient's unplanned transfer for two (Record/Patient #1 and #2) of two transfer records reviewed. This deficient practice has the potential to affect the post-discharge care of all patients served by the agency. Findings included: Review of the agency's policy titled, "Discharge Summary," dated 01/12/2018 showed: - Purpose: To ensure that appropriate information related to the care, treatment and/or services provided is exchanged with other service members when patients are transferred or discharged from the agency; - Staff are responsible for notifying the ordering physician(s) of pending transfer or discharge and ensuring that appropriate orders are received and documented in the medical record; - Transfer/discharge summary information include but not limited to: - Summary of the patient's mental, physical, and emotional status at the time of discharge/transfer; - Date, initiation, and reason for transfer or discharge; - The extent to which goals were met and any referrals made; - Documentation of notification of all physicians issuing orders for the plan of care, patient, and patient's legal representative (if any) and family regarding the termination of service; - The primary professional disciplines, including skilled nursing (SN), physical therapy (PT), speech therapy, occupational therapy (OT), and social services will complete the Discharge Summary form and the completed form will be sent to the attending physician for signature; and - The completed transfer/discharge summary shall be sent to the patient's primary care practitioner or other responsible healthcare professional within the following timeframes: - Discharge: Within five business days of the patient's discharge, - Planned transfer: Within two business days; and - Unplanned transfer: Within two business days of becoming aware of the unplanned discharge. RECORD/PATIENT #1: Review of the patient's plan of care (POC) dated 12/15/2020 through 02/12/2021 showed: - Start of care date 12/15/2020; and - Diagnoses included but not limited to poly neuropathy (damage to the peripheral nerves, and signs may include a prickling, burning, or numb sensation), colostomy (a surgical procedure that creates an opening for the colon, or large intestine, through the abdominal wall for the excretion of fecal material), end stage renal (kidney) failure, chronic kidney disease. Review of the hospital record date 12/28/2020 showed the patient was admitted to the hospital on 12/28/2020 with a diagnosis of pain in the left lower extremity. Review of the "Care Summary Including Oasis (assessment tool) Elements for Transfer to an Inpatient Facility" form dated 12/29/2020 showed: - Time in: Not (no visit made); - Brief description of patient's home health agency care: Patient admitted to hospital; - Signed by the physical therapist at 9:00 AM on 12/29/2020; - No summary of skilled nursing care or current medications recorded on the summary; and - No recorded indication of who the incomplete summary was sent to at the time of the unplanned transfer. During an interview on 01/13/2021 at 9:30 AM, the assistant administrator stated: - Only the non-comprehensive transfer summary completed by the PT was sent to the primary care physician and no current medication list was sent; - The summaries are sent to the physician only and they are sent the day they are written; - No comprehensive summary to include SN and medication summaries along with the PT summary was sent to the primary care physician or to the admitting hospital after becoming aware of the unplanned transfer on 12/28/2020. RECORD/PT #2; Review of the patient's POC dated 11/14/2020 through 01/12/2021 showed: - Start of care date 11/14/2020; - Diagnoses include but not limited to: Diabetes mellitus, chronic foot and lower leg ulcers; and - SN and home health aide services. Review of the "Care Summary Including Oasis Elements for Transfer to an Inpatient Facility" form dated 12/21/2020 showed: - No visit; - The SN did not recorded any information on the summary page related to a brief description of the patient's home health care administered by other disciplines or current medications; - Transferred to the ER for shortness of breath; and - No recorded indication of who the incomplete summary was sent to at the time of the unplanned transfer. Review of a missed visit SN note dated 12/21/2020 showed the patient was admitted to the hospital. RECORD/PATIENT #5: Review of the patient's POC dated 11/10/2020 through 01/08/2021 showed: - Start of care date 11/10/2020; - Diagnoses included but not limited to: Pain in left leg and asthma; and - PT services only. Review of the Discharge Summary dated 12/10/2020 showed: - No current medication list included with faxed summary by the PT. RECORD/PATIENT #4: Review of the patient's POC dated 10/14/2020 through 12/12/2020 showed: - Start of care date 10/14/2020; and - Diagnoses included but not limited to: paraplegia (paralysis of the legs and lower body), repeated falls, dysphagia (difficulty swallowing) and hypertension; and - SN, PT, OT and home health aide services. Review of the Discharge Summary dated 11/24/2020 showed: - No list of services and frequency; - No current medication list included with faxed summary by the PT; and - No mention of patient's discharge condition. During an interview on 01/13/2021 at 9:30 AM, the assistant administrator stated: - Only the discharge or transfer summary is sent to the attending physician; - The summary is not sent to the receiving facility or other professional who would be responsible for continued care; and - No current medication lists are sent to the receiving facility or other professional who would be responsible for continued care.