Every finding on record at Kismet Lgn, LLC

The recertification survey, conducted 3/8/2021 through 3/10/2021 found the agency operating out of compliance with the following requirements of the Establishment of Emergency Preparedness:

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 agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in the agency's emergency preparedness policies and procedures to 4 of 4 contracted therapy staff consistent with their expected roles in the event of an emergency/disaster. The agency reported 4 therapy staff by contract at the time of the survey. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: The agency emergency preparedness book lacked documentation of training for any staff hired by contract. During agency staff interview on 3/10/2021 at 8:15 AM, the Administrator reported she had not been having any contracted therapy staff participate in training to the agency's emergency preparedness plan or any of the trainings held as a result of changes to the Plan. The agency's emergency preparedness plan was updated with information related to the Covid 19 pandemic on 3/26/2020 and 10/9/2020. The agency held training sessions on each of these dates to review the changes to the Plan. The Administrator verified the agency did not have documentation of emergency preparedness training/review of updates during 2018, 2019 or 2020 for Staff A, contracted Physical Therapist; Staff C, contracted Physical Therapy Assistant; Staff D, Speech Therapist and Staff E, Occupational Therapist. The agency did not provide training for the agency's emergency preparedness/disaster plan to assure each contracted employee's understanding of the plan initially and with changes to the Plan or at least every 2 years. The above stated findings were reviewed with the Administrator. The agency provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 3/8/21 through 3/10/21 . The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the agency operating out of compliance with multiple standard level regulatory requirements.

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 clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review as part of the update to the comprehensive assessment for 2 of 7 sampled patients (Patients #1 and #6). The agency reported a current patient census of 16 patients. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: According to the agency policy, titled Initial Assessments/Comprehensive Assessments and dated 1/2020, the registered nurse (RN) will complete a drug regimen review as part of each comprehensive assessment. According to the agency policy, titled Drug Regimen Review and dated 12/2020, defined the drug regimen review as a review of all medications the patient currently takes 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. During agency staff interview on 3/10/2021 at 3:15 PM, the Clinical Manager reported the clinicians reconcile all of the medications taken by the patient with each medication change and with all comprehensive assessments at start of care, resumption of care, recertification, significant change in condition and discharge. The clinician documents the drug regimen review in the communication note section of the agency's electronic clinical record system. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record review revealed the following: a. The Plans of Care, dated 12/4/2020 to 2/1/2021 and 2/2/2021 to 4/2/2021, included physician orders for skilled nursing and home health aide services. b. The clinical record included an update to the comprehensive assessment at the time of recertification, dated 2/1/2021. c. The communication notes lacked documentation of a drug regimen review completed in conjunction with the updated recertification assessment. d. During agency staff interview on 3/10/2021 at 8:50 AM, the Administrator reported reviewing Patient #1's electronic clinical record, reporting an inability to locate documentation indicating a registered nurse completed a drug regimen review as part of the update to the comprehensive assessment dated 2/1/2021. 2. Patient #6 had a start of care date of 5/1/2020 and was discharged from agency services on 11/12/2020. Clinical record review revealed the following: a. The Plans of Care, dated 5/1/2020 to 6/29/2020, 6/30/2020 to 8/28/2020, 8/29/2020 to 10/27/2020 and 10/28/2020 to 12/26/2020, included physician orders for skilled nursing services. b. The clinical record included a transfer to inpatient facility, dated 5/6/2020, documenting Patient #6 was hospitalized on 5/6/2020 with increased creatinin levels. The clinical record included an update to the comprehensive assessment at the time of resumption of care, dated 5/7/2020. The communication notes lacked documentation of a drug regimen review completed in conjunction with the updated resumption of care assessment. c. The clinical record included an update to comprehensive assessment at the time of discharge, dated 11/12/2020. The communication notes lacked documentation of a drug regimen review completed in conjunction with the updated discharge assessment. d. During agency staff interview on 3/9/2021 at 4:25 PM, the Administrator reported reviewing Patient #6's electronic clinical record, reporting an inability to locate documentation indicating a registered nurse completed a drug regimen review as part of the update to the comprehensive assessments dated 5/7/2020 and 11/12/2020. The above stated findings for Patients #1 and #6 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments with accompanying drug regimen review between day 56 and 60 of each 60 day certification period for 5 of 7 sampled patients requiring an update to the comprehensive assessment at the time of recertification (Patients #1, #2, #3, #4 and #6). The agency reported a census of 16 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Initial Assessments/Comprehensive Assessments and dated 1/2020, the registered nurse (RN) will complete a drug regimen review as part of each comprehensive assessment. According to the agency policy, titled Reassessments/Update of the Comprehensive Assessment and dated 1/2020, an update to the comprehensive assessment for recertification will be completed within the last five days (days 56-60 of the current period) of every 60 day episode, beginning with the start of care. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record revealed the following: a. The Plans of Care, dated 8/6/2020 to 10/4/2020 and 10/5/2020 to 12/3/2020, included physician orders for skilled nursing and home health aide services. The update to the comprehensive assessment at the time of recertification, dated as initiated on 10/2/2020 (day 58 of the certification period) but was not completed until 10/6/2020, 2 days into the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 10/7/2020. The certification period ended on 10/4/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. b. The Plans of Care, dated 10/5/2020 to 12/3/2020 and 12/4/2020 to 2/1/2021, included physician orders for skilled nursing and home health aide services. The patient was hospitalized on 11/30/2020 and returned home on 12/3/2020, day 60 of the certification period. The update to the comprehensive assessment at the time of recertification (combined with the resumption of care comprehensive assessment) was not initiated until 12/4/2020, the first day of the new certification period. The assessment was not completed until 12/5/2020, 2 days into the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 12/7/2020. The certification period ended on 12/3/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. 2. Patient #2 had a start of care date of 9/14/2020. Clinical record revealed the following: The Plans of Care, dated 9/14/2020 to 11/12/2020, included physician orders for skilled nursing and home health aide services. (The agency continued to provide both services for an additional 60 days following the Plan but failed to complete a new Plan of Care for the period of 11/13/2020 to 1/11/2021.) The update to the comprehensive assessment at the time of recertification, dated as initiated on 11/10/2020 (day 58 of the certification period) was signed as completed on 11/11/2020 (day 59 of the certification period); however, the drug regimen review to accompany the update to the comprehensive assessment at the time of recertification was dated 11/15/2020, 3 days into the next planned certification period. The certification period ended on 11/12/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. 3. Patient #3 had a start of care date of 8/31/04. Clinical record review revealed the following: a. The Plans of Care, dated 6/15/2020 to 8/13/2020 and 8/14/2020 to 10/12/2020, included physician orders for home health aide services for personal care assistance with supervision by a registered nurse every 60 days. The update to the comprehensive assessment at the time of recertification was signed as completed 8/12/2020; however, the drug regimen review to accompany the update to the comprehensive assessment at the time of recertification was dated 8/16/2020, 3 days into the next certification period. The certification period ended on 8/13/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. b. The Plans of Care, dated 8/14/2020 to 10/12/2020 and 10/13/2020 to 12/11/2020, included physician orders for home health aide services for personal care assistance with supervision by a registered nurse every 60 days. The update to the comprehensive assessment at the time of recertification, dated as initiated on 10/9/2020 (day 57 of the certification period) but was not completed until 10/13/2020, 1 day into the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 10/13/2020. The certification period ended on 10/12/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. c. The Plans of Care, dated 10/13/2020 to 12/11/2020 and 12/12/2020 to 2/9/2021, included physician orders for home health aide services for personal care assistance with supervision by a registered nurse every 60 days. The update to the comprehensive assessment at the time of recertification, dated as initiated on 12/16/2020 (5 days after the new certification period had already begun) and was signed as complete on 12/17/2020, 6 days into the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 12/17/2020. The certification period ended on 12/11/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. The clinical record lacked any documentation indicating the physician was contacted to delay the collection of recertification comprehensive assessment information. During agency staff interview on 3/10/2021 at 8:45 AM, the Administrator reported the patient was exposed to Covid 19 and refused the visit at the end of the certification period to decrease the risk of agency staff exposure. The Administrator verified the physician had not been contacted to obtain approval to delay the comprehensive assessment or to obtain direction on how to care for the patient until the patient would allow the recertification assessment to occur. 4. Patient #4 had a start of care date of 6/2/2020. Clinical record revealed the following: a. The Plans of Care, dated 8/1/2020 to 9/29/2020 and 9/30/2020 to 11/28/2020, included physician orders for skilled nursing and home health aide services. The update to the comprehensive assessment at the time of recertification, dated as initiated on 9/29/2020 (day 60 of the certification period) but was not completed until 9/30/2020, 1 day into the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 9/30/2020. The certification period ended on 9/29/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. b. The Plans of Care, dated 11/29/2020 to 1/27/2021 and 1/28/2021 to 3/28/2021, included physician orders for skilled nursing and home health aide services. The update to the comprehensive assessment at the time of recertification was not initiated until 1/28/2021, the first day of the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 1/28/2021. The certification period ended on 1/27/2021. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. 5. Patient #6 had a start of care date of 5/1/2020 and was discharged from agency services on 11/12/2020. Clinical record revealed the following: The Plans of Care, dated 6/30/2020 to 8/28/2020 and 8/29/2020 to 10/27/2020, included physician orders for skilled nursing services. The update to the comprehensive assessment at the time of recertification, dated as initiated on 8/28/2020 (day 60 of the certification period) but was not completed until 8/31/2020, 3 days into the new certification period. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 8/31/2020. The certification period ended on 8/28/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. The above stated findings for Patients #1, #2, #3, #4 and #6 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure completion of the update to the comprehensive assessment with accompanying drug regimen review within 48 hours of the agency's knowledge of return home from an inpatient facility for 2 of 3 sampled patients requiring a resumption of care assessment (Patients #1 and #6). The agency provided services to 16 patients at the time of the survey and performed 4 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Initial Assessments/Comprehensive Assessments and dated 1/2020, the registered nurse (RN) will complete a drug regimen review as part of each comprehensive assessment. According to the agency policy, titled Reassessments/Update of the Comprehensive Assessment and dated 1/2020, an update to the comprehensive assessment for resumption of care following a hospital inpatient admission will be completed within 48 hours of the patient's return home from the facility or on the physician ordered resumption of care date. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record review revealed the following: a. The patient was hospitalized for treatment of a foot ulcer on 11/30/2020 and returned home on 12/3/2020. The update to the comprehensive assessment at the time of resumption of care, dated 12/4/2020, documented the patient was discharged from the hospital on 12/3/2020 and the agency received the referral for resumption of care on 12/3/2020. The nurse initiated the update to the assessment on 12/4/2020 but did not complete the accompanying drug regimen review until 12/7/2020, 4 days after the patient's return home from the inpatient stay. The assessment was completed 2 days late as required by regulation and the agency's own policy. During agency staff interview on 3/10/2021 at 9:00 AM, the Administrator concurred the patient should have either had resumption of care occur on 12/3/2020, the last day of the certification period, or be discharged and readmitted to services when the resumption of care could occur. b. The patient was hospitalized for treatment of high blood sugars/diabetes on 2/24/2021 and returned home on 2/18/2021. The update to the comprehensive assessment at the time of resumption of care, dated 2/19/2021, documented the patient was discharged from the hospital on 2/18/2021 and the agency received the referral for a physician ordered resumption of care visit on 2/19/2021. The nurse initiated the update to the assessment on 2/19/2021 as directed by the physician but did not complete the assessment or the accompanying drug regimen review until 2/22/2020, 3 days after the physician ordered resumption of care date. The assessment was completed 1 day late as required by regulation and the agency's own policy. 2. Patient #6 had a start of care date of 5/1/2020 and was discharged from agency services on 11/12/2020. Clinical record review revealed the following: The patient was hospitalized for treatment of stroke like symptoms on 10/6/2020 and returned home on 10/13/2020. The update to the comprehensive assessment at the time of resumption of care, dated 10/14/2020, documented the patient was discharged from the hospital on 10/13/2020 and the agency received the referral for a physician ordered resumption of care visit on 10/13/2020. The nurse initiated the update to the assessment on 10/14/2020 but did not complete the accompanying drug regimen review until 10/16/2020, 3 days after the agency became aware of the patient's hospital discharge. The assessment was completed 1 day late as required by regulation and the agency's own policy. The above stated findings for Patients #1 and #6 were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #5). The agency reported a census of 16 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 3/2019, each patient must receive home health services that are written in an individualized Plan of Care signed by the patient's physician. Recertification of the Plan of Care must be completed at least every 60 days when there is a need to continue home health care after the initial 60 day episode of care. The updated individualized Plan of Care must be reviewed and signed by the physician responsible for the home health Plan of care. Consultation with the physician on any modification in the Plan of Care will be documented. Agency professional staff will promptly alert the physician to any changes that suggest a need to alter the Plan of Care. Care and services will be provided according to physician orders and all orders will be kept current and updated. If the agency misses a visit, treatment or service as required by the Plan of Care, the agency must notify the responsible physician of such missed treatments or services for direction. During agency staff interview on 3/8/2021 at 3:15 PM, the Clinical Manager reported if visit frequency differs from the Plan of Care, a missed visit note is completed by the clinician, documenting why the visit was missed and then sent to the physician by facsimile. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record review revealed the following: a. The Plan of Care, dated 12/4/2020 to 2/1/2021, included physician orders for home health aide visits 3 times per week. The clinical record included documentation of only one home health aide visit during the week of 1/3/2021 to 1/9/2021. The clinical record included a missed visit note, dated 1/8/2021, documenting a missed visit occurred on 1/8/2021 but lacked documentation of any physician communication or notification for the second missed visit during that same week. The clinical record lacked documentation of why the third visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. b. The physician's resumption of care order, dated 1/20/2021, ordered home health aide services twice weekly for one week, then 3 times weekly for the remainder of the certification period. The clinical record included documentation of two home health aide visits during the weeks of 1/20/2021 to 1/23/2021 and 1/24/2021 to 1/30/2021. The clinical record lacked documentation of why the third visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. c. The physician's resumption of care order, dated 1/20/2021, ordered an occupational therapy evaluation with plan to treat as needed. The clinical record lacked documentation of the completion of the occupational therapy evaluation or any further treatment. The clinical record lacked documentation of why the occupational therapy evaluation did not occur as ordered by the physician and lacked any communication with the physician to discuss that inability to follow the Plan of Care and obtain direction on how to proceed. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order discontinuing the need for an occupational therapy evaluation and treatment. During agency staff interview on 3/10/2021 at 9:00 AM, the Administrator reported the patient refused the occupational therapy visit as he/she paid privately for all home health services and the evaluation/treatment fees were too costly. 2. Patient #2 had a start of care date of 9/14/2020. Clinical record review revealed the following: a. The Plan of Care, dated 9/14/2020 to 11/12/2020, included physician orders for skilled nursing services every other week and home health aide visits twice weekly. b. The update to the comprehensive assessment at the time of recertification, dated 11/10/2020, documented a continued need for skilled nursing and home health aide services. c. The clinical record lacked documentation of any Plan of Care completed by the clinician or returned signed by the physician. d. The skilled nurse continued to provide services every other week and the home health aide twice weekly from 11/13/2020 to 1/11/2021 continued to provide services. During agency staff interview on 3/10/2021 at 2:30 PM, the Administrator reported she had reviewed the patient's electronic clinical record and was unable to locate any Plan of Care for the period of 11/13/2020 to 1/11/2021. 3. Patient #3 had a start of care date of 8/31/2004. Clinical record review revealed the following: The Plan of Care, dated 12/12/2020 to 2/9/2021, included physician orders for home health aide visits 5 times per week. a. The clinical record included documentation of only four home health aide visits during the week of 1/3/2021 to 1/9/2021. The clinical record lacked documentation of why the fifth visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. b. The clinical record included documentation of only 3 home health aide visits during the week of 1/24/2021 to 1/30/2021. The clinical record included a missed visit note, dated 1/25/2021, documenting a missed visit occurred on 1/25/2021 due to inclimate weather but lacked documentation of any physician communication or notification for the second missed visit during that same week. The clinical record lacked documentation of why the fifth visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. The Plan of Care, dated 2/10/2021 to 4/10/2021, included physician orders for home health aide visits 5 times per week. c. The clinical record lacked documentation of any home health aide visits during the week of 2/21/2021 to 2/27/2021 and included documentation of only 3 home health aide visits during the week of 2/28/2021 to 3/6/2021. The clinical record lacked documentation of why the aide visits were not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. d. During agency staff interview on 3/10/2021 at 9:20 AM, the Administrator reported the patient's usual home health aide was on vacation from 2/21/2021 through 3/1/2021. The family only wants that home health aide to provide care so no services were provided. 4. Patient #4 had a start of care date of 6/2/2020. Clinical record review revealed the following: The Plan of Care, dated 1/28/2021 to 3/28/2021, included physician orders for home health aide visits twice weekly. The clinical record included documentation of only 1 home health aide visit during the week of 2/21/2021 to 2/27/2021. The clinical record lacked documentation of why the aide visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. 5. Patient #5 had a start of care date of 3/20/2020. Clinical record review revealed the following: The Plan of Care, dated 1/14/2021 to 3/14/2021, included physician orders for home health aide visits twice weekly. a. The clinical record included documentation of only 1 home health aide visit during the week of 1/24/2021 to 1/30/2021. The clinical record lacked documentation of why the aide visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in home health aide visit frequency as described above. The Plans of Care, dated 11/15/2020 to 1/13/2021 and 1/14/2021 to 3/14/2021, included physician orders for skilled nursing visits every other week. b. The clinical record included documentation of a skilled nurse visit on 1/12/2021. The next skilled nurse visit occurred on 2/2/2021, 20 days after the 1/12/2021 visit. The clinical record lacked documentation of why the skilled nurse visit was not made as ordered and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile as required by agency policy. The clinical record lacked any interim physician order directing a change in the skilled nurse visit frequency as described above. The above stated findings for Patients #1, #2, #3, #4 and #5 were reviewed with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, patient interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate medication orders for 4 of 7 sampled patients (Patients #1, #2, #3 and #4). The agency reported a current census of 16 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Plan of Care-CMS #485 and Physician Orders, dated 3/2019, the individualized plan of care must include the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, the types of services, supplies and equipment required, the frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, all medications and treatments used by the patient, safety measures to protect against injury, a description of the patient's risk for emergency hospitalization and hospital readmission, discharge planning, patient-specific interventions and education and measurable outcomes and goals, information related to advance directives, and all patient care orders, including verbal orders. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record review, home visit observation and accompanying interviews revealed the following: a. On 3/10/2021 at 12:30 PM, the surveyor accompanied the Clinical Manager to Patient #1's home. During the home visit the surveyor noted the patient had a CPAP (a machine used to assist the patient with breathing effectively when sleeping, a glucometer (a machine used to monitor blood sugar levels) and incontinence liners in the home. b. During patient interview while in the home, Patient #1 reported monitoring his/her own blood sugars multiple times daily, currently used the CPAP machine when sleeping and wore pads for urinary incontinence. c. The Emergency Preparedness Plan documented the patient used oxygen equipment for the CPAP machine and had a blood glucose machine (glucometer). During agency staff interview on 3/10/2021 at 9:00 AM, the Clinical Manager verified Patient #1 used liners for incontinence, used a CPAP when sleeping and self monitored blood glucose levels using a glucometer. The Plans of Care, dated 8/6/2020 to 10/4/2020, 10/5/2020 to 12/3/2020, 12/4/2020 to 2/1/2021 and 2/2/2021 to 4/2/2021, lacked identification of the CPAP, glucometer and incontinence products as equipment used by the patient to meet his/her needs. d. During the same home visit, the surveyor observed a bottle of Acetaminophen 500 milligram (mg) tablets. The surveyor noted the bottle initially contained 500 caplets and appeared approximately 3/4 of the tablets were no longer in the bottle. During patient interview while in the home, Patient #1 reported taking 2- 500 mg tablets as needed (prn) for pain. The Plan of Care, dated 2/2/2021 to 4/2/2021, included orders for "Acetaminophen 325 mg 2 tablets prn". The Plan of Care did not include the correct dosage of Acetaminophen taken by the patient. Clinical record review revealed the following: The Plans of Care, dated 8/6/2020 to 10/4/2020, 10/5/2020 to 12/3/2020, 12/4/2020 to 2/1/2021 and 2/2/2021 to 4/2/2021, included the following incomplete medication orders: e. "Lomotil 5 mg one tablet prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. f. "Ibuprofen 200 mg prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. g. "Pseudophrine 30 mg one tablet prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. h. Acetaminophen 325 mg two tablets prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. i. "Glucose tablets one tablet prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. 2. Patient #2 had a start of care date of 9/14/2020. Clinical record review, home visit observation and accompanying agency staff interview revealed the following: a. On 3/10/2021 at 10:05 AM, the surveyor accompanied the Clinical Manager and Staff B, Home Health Aide, to Patient #2's home. During the home visit the surveyor noted the patient had an oxygen concentrator and portable oxygen tank in the home. b. The Plan of Care, dated 1/12/2021 to 3/12/2021, documented the patient's use of the oxygen equipment as equipment used by the patient. The Plan of Care failed to include physician orders for the amount of oxygen, mode of administration and frequency of use. c. During the same home visit, the Clinical Manager noted the patient's pulse oxygen reading was 71% following ambulation from the bathroom to the kitchen area. During agency staff interview while in the home, the Clinical Manager reported she did not find orders for the oxygen on the Plan of Care. The oxygen concentrator had a nasal cannula attached and was set at 2 liters. The Clinical Manager put the nasal cannula on the patient, turned on the concentrator and immediately contacted the physician's office to obtain direction for the oxygen use and report the low blood oxygen level. d. During the same home visit, the surveyor observed 3 urinals filled with urine on the counter in the kitchen. Staff B, Home Health Aide, emptied each of the urinals in the patient's toilet and replaced the urinals back on the counter. The Plan of Care, dated 1/12/2021 to 3/12/2021, did not included urinals as equipment used to meet the patient's needs. 3. Patient #3 had a start of care date of 8/31/2004. Clinical record review revealed the following: The Plans of Care, dated 10/13/2020 to 12/11/2020, 12/12/2020 to 2/9/2021 and 2/10/2021 to 4/10/2021, included the following incomplete medication orders: a. "Clonazepam 0.5 mg one tablet prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. b. "Children's Motrin 100 mg/5 milliliters 3.5 tsp prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. c. "Pepto Bismol 5 milliliters prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. 4. Patient #3 had a start of care date of 8/31/2004. Clinical record review revealed the following: The Plans of Care, dated 8/1/2020 to 9/29/2020, 9/30/2020 to 11/28/2020, 11/29/2020 to 1/27/2021 and 1/28/2021 to 3/28/2021, included the following incomplete medication orders: a. "Tums 1000 mg 1-2 tablets prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. b. "Miralax 17 grams prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. c. "Linzess 145 micrograms prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. d. "Alprazolam 0.25 mg prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. e. "Acetaminophen 325 mg 1-2 tablets prn". The order lacked a frequency for how often the patient could take the medication and the physician's pre-approved reason for taking the medication on an as needed basis. The above findings for Patients #1, #2, #3 and #4 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy review, agency staff interview and clinical record review, the agency skilled professionals failed to follow the physician ordered Plan of Care for 1 of 6 sampled patients receiving a skilled service (Patient #1). The agency reported a current census of 16 patients, including 15 who received skilled services. Failure to ensure that skilled professionals provided care only as ordered by the physician increased the risk that patients' health care needs would not be adequately met in a safe manner. Findings include: According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 3/2019, home health services will be in accordance with the Plan of Care based on the diagnosis and assessment of needs and resources. The individualized Plan of Care must specify the care and services necessary to meet the needs of the patient, including identification of the responsible discipline(s) responsible for the task. The physician must approve the Plan of Care. Drugs, services, treatments and all clinical services are administered by staff only as ordered by the physician. On 3/8/2021 at 3:15 PM, the Clinical Manager reported all documentation with the physician would be documented either in the visit note, in the communication notes or sent to the physician by facsimile. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record review revealed the following: a. The Plans of Care, dated 12/4/2020 to 2/1/2021 and 2/2/2021 to 4/2/2021, included physician orders for the skilled nurse to visit the patient 3 times weekly to monitor compliance with diabetic regimen, reporting any blood sugar readings less than 60 or greater than 120. b. The skilled nurse visit notes, dated 1/8, 2/5, 2/9, 2/12, 2/20 and 2/26/2021, lacked documentation indicating the skilled nurse monitored the patient's blood glucose level or reviewed any blood glucose readings documented by the patient between visits in order to determine if the patient's blood glucose levels fell outside the physician ordered reporting parameters. c. The update to the comprehensive assessments at the time of resumption of care, dated 1/20/2021 and 2/19/2021, lacked an assessment of the patient's blood glucose readings and lacked evidence the skilled nurse monitored the patient's blood glucose level during the visit to determine if the patient's blood glucose levels fell outside the physician ordered reporting parameters. d. The skilled nurse visit notes documented the following: 12/31/2020- blood glucose 154 1/27/2021- blood glucose 224 1/28/2021- blood glucose 180 1/29/2021- blood glucose 177 2/3/2021- blood glucose 296 2/22/2021- blood glucose 232 2/24/2021- blood glucose 231 3/3/2021- blood glucose 258 3/5/2021- blood glucose 289 The skilled nurse visit notes lacked documentation of physician notification of the blood glucose levels exceeding the physician ordered reporting parameters. The clinical record lacked documentation of any communication notes indicating the skilled nurse reported the above stated parameters or consulted the physician by facsimile to report the high levels. e. The physician's interim order, dated 2/18/2021, ordered an extra skilled nurse visit to change the patient's lower leg dressings on 2/19/2021 and then prn (as needed) thereafter. The update to the comprehensive assessment at the time of resumption of care, dated 2/19/2021, lacked documentation of completion of the dressing change to either of the patient's legs. The skilled nurse visit note, dated 2/20/2021, documented the skilled nurse changed the patient's leg dressings as ordered by the physician in the interim order. The nurse did not perform the dressing changes on the date ordered by the physician. The above stated findings for Patient #1 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on clinical record review, personnel file review and agency staff interview, the agency failed to ensure 1 of 2 sampled home health aides (Staff B), demonstrated competency in extra skills prior to being independently assigned to a patient requiring the extra skill completion for 3 patients (Patients #1, #2 and #7). The agency reported a current census of 16, including 11 who received home health aide services at the time of the survey. The agency employed 2 home health aides at the time of the survey. Findings include: Clinical record review and review of personnel file documents revealed the following: 1. Patient #1 had a start of care date of 6/10/2010. The Plans of Care, dated 12/4/2020 to 2/1/2021 and 2/2/2021 to 4/2/2021, included physician orders for home health aide visits 3 times weekly. a. The home health aide care plan/assignments, dated 2/1/2021 and 3/1/2021, included direction to the home health aide to remove and apply compression stockings, assist with the application of lymphedema pumps and apply a medicated topical powder under the patient's breast and abdominal apron. b. Home Health Aide visit notes documented Staff B, Home Health Aide, provided services to Patient #1 independently routinely between 12/4/2020 and the time of the survey. c. Review of Staff B, Home Health Aide's personnel file revealed Staff B was hired by the agency on 6/4/2017. The personnel file lacked documentation of a competency evaluation for the application of compressions stockings, lacked documentation of a competency evaluation for the application of lymphedema pumps and lacked documentation of a competency evaluation for the application of a medicated topical powder. 2. Patient #2 had a start of care date of 9/14/2020. The Plans of Care, 1/12/2021 to 3/12/2021, included physician orders for home health aide visits 2 times weekly. a. The home health aide care plan/assignments, dated 1/11/2021 and 3/1/2021, included direction to the home health aide to remove and apply compression stockings, shave the patient and apply a medicated topical ointment to the patient's buttocks. b. Home Health Aide visit notes documented Staff B, Home Health Aide, provided services to Patient #2 independently routinely between 1/11/2020 and the time of the survey. c. Review of Staff B, Home Health Aide's personnel file revealed Staff B was hired by the agency on 6/4/2017. The personnel file lacked documentation of a competency evaluation for the application of compressions stockings, lacked documentation of a competency evaluation for shaving a patient and lacked documentation of a competency evaluation for the application of a medicated topical ointment. 3. Patient #7 had a start of care date of 10/23/2020 and was discharged from home health services on 3/9/2021. The Plans of Care, 12/22/2020 to 2/19/2021 and 2/20/2021 to 4/20/2021, included physician orders for home health aide visits 2 times weekly. a. The home health aide care plan/assignments, dated 2/10/2021 and 3/5/2021, included direction to the home health aide to remove and apply compression stockings. b. Home Health Aide visit notes documented Staff B, Home Health Aide, provided services to Patient #7 independently routinely between 2/10/2020 and 3/9/2021. c. Review of Staff B, Home Health Aide's personnel file revealed Staff B was hired by the agency on 6/4/2017. The personnel file lacked documentation of a competency evaluation for the application of compressions stockings. During agency staff interview on 3/10/2021 at 2:45 PM, the Administrator verified she had not performed any extra skill competency evaluations for Staff B, Home Health Aide. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, agency staff interview and patient interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 6 sampled patients receiving home health aide services (Patients #2 and #7). The agency reported a census of 16 patients, including 11 who received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: According to agency's undated policy, titled Home Health Aide/HCBS Assignments, the home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional. The policy directed the skilled professionals to consider specific medical and psychological needs of the patient, the patient's preferences, the patient's environment and length/frequency of visits when developing the assignment. 1. Patient #2 had a start of date of 9/14/2020. The Plans of Care, dated 9/14/2020 to 11/12/2020 and 1/12/2021 to 3/12/2021 (please see G572 for information on missing Plan of Care), included physician orders for skilled nursing services and home health aide services. Clinical record review revealed: The home health aide assignment/care plans, dated 1/11/2021 and 3/1/2021, directed the aides to "trim the patient's fingernails prn (as needed)" and "trim the patient's toenails prn (as needed)", thereby allowing the aide to decide whether to trim the fingernails and toenails or not. The assignment required the home health aide to assess to determine when the trimming of each was required, which exceeds the scope of practice of a home health aide. 2. Patient #7 had a start of date of 10/23/2020 and was discharged from home health services on 3/9/2021. The Plans of Care, dated 12/22/2020 to 2/19/2021 and 2/20/2021 to 4/20/2021, included physician orders for skilled nursing services and home health aide services. Clinical record review revealed: The home health aide assignment/care plans, dated 2/10/2021 and 3/5/2021, directed the aides to "trim the patient's toenails prn (as needed)", thereby allowing the aide to decide whether to trim the toenails or not. The assignment required the home health aide to assess to determine when the trimming of each was required, which exceeds the scope of practice of a home health aide. The above findings for Patients #2 and #7 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the 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 agency policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 5 of 6 sampled patients receiving home health aide services (Patients #1, #2, #3, #5 and #7). The agency reported a current census of 16 patients at the time of the survey, including 12 who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to the agency policy, titled Home Health Aide Documentation and dated 3/2018, the home health aide will document all services rendered to the patient on the appropriate home health aide charting form as directed in the aide care plan/assignment sheet. According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 3/2019, home health services will be in accordance with the Plan of Care based on the diagnosis and assessment of needs and resources. The individualized Plan of Care must specify the care and services necessary to meet the needs of the patient, including identification of the responsible discipline(s) responsible for the task. The physician must approve the Plan of Care. Drugs, services, treatments and all clinical services are administered by staff only as ordered by the physician. 1. Patient #1 had a start of care date of 6/10/2010. Clinical record review revealed the following: a. The home health aide care plan/assignments, dated 2/1/2021 and 3/1/2021, included direction to the aide to remove and apply compression stockings every visit and to assist the patient with applying a lymphedema pump after showering every visit. Applying compression stockings and lymphedema pumps are both an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plan of Care, dated 2/2/2021 to 4/2/2021, lacked physician approval for the home health aide to apply the compression stockings and the lymphedema pumps as an extension of nursing services. b. The home health aide care plan/assignments, dated 2/1/2021 and 3/1/2021, included direction to the aide to apply gold bond powder under the breast area and abdominal apron every visit. The home health aide visit notes, dated 2/3, 2/5,8, 2/10, 2/12, 2/24 and 2/26/2021, lacked documentation of the aide aide applying the gold bond powder as directed by the nurse. The same notes lacked documentation of the reason for omission of the task. c. The home health aide care plan/assignments, dated 2/1/2021 and 3/1/2021, included direction to the aide to assist with the application of lymphedema pumps to each lower leg every visit. The home health aide visit notes, dated 2/3, 2/5, 2/8, 2/10, 2/12, 2/24 and 2/26/2021, lacked documentation of the aide aide assisting with the application of the lymphedema pumps during the visits as directed by the nurse. The same notes lacked documentation of the reason for omission of the task. 2. Patient #2 had a start of care date of 9/14/2020. Clinical record review revealed the following: The home health aide care plan/assignments, dated 1/11/2021 and 3/1/2021, included direction to the aide to shower the patient every visit, shave the patient every visit, apply calmoseptine to the patient's buttocks every visit, apply A&D ointment to the patient's buttocks every visit, remove and apply compression stockings every visit. a. The home health aide visit notes, dated 1/22, 1/25, 1/29, 2/3, 2/10, 2/12, 2/15 and 2/17/2021, lacked documentation of the aide showering the patient. Instead of the shower, the aide performed a sponge bath instead. Sponge bath had never been assigned to the aide. The same notes lacked documentation of the reason for omission of the task. b. The home health aide visit notes, dated 1/11, 1/13, 1/22, 1/29, 2/3, 2/10, 2/12 and 2/24/2021, lacked documentation of the aide shaving the patient. The same notes lacked documentation of the reason for omission of the task. c. The home health aide visit notes, dated 1/11, 1/13, 1/18, 1/20, 1/22 1/25, 1/27, 1/29, 2/1, 2/3, 2/5, 2/8, 2/10, 2/12, 2/15, 2/17, 2/19, 2/24 and 2/26/2021, lacked documentation of the aide applying calmoseptine to the patient's buttocks. The same notes lacked documentation of the reason for omission of the task. d. The home health aide visit notes, dated 1/11, 1/13, 1/18, 1/20, 1/22, 1/25, 1/27, 1/29, 2/1, 2/3, 2/5, 2/8, 2/10, 2/12, 2/15, 2/17, 2/19, 2/24 and 2/26/2021, lacked documentation of the aide applying A&D ointment to the patient's buttocks. The same notes lacked documentation of the reason for omission of the task. e. The home health aide visit notes, dated 1/22, 1/25, 1/29, 2/1, 2/3, 2/5, 2/8 and 2/10/2021, lacked documentation of the aide removing and applying compression stockings. The same notes lacked documentation of the reason for omission of the task. 3. Patient #3 had a start of care date of 8/31/2004. Clinical record review revealed the following: The home health aide care plan/assignments, dated 10/9/2020 and 2/5/2021, included direction to the aide to apply a brace to the patient's left lower extremity. The home health aide visit notes, dated 1/11, 1/18, 1/20, 2/1, 2/2, 2/8, 2/9, 2/10, 2/11 and 3/4/2021 lacked documentation of the aide applying the brace to the patient's left lower extremity. The same notes lacked documentation of the reason for omission of the task. 4. Patient #5 had a start of care date of 3/20/20. Clinical record review revealed the following: The home health aide care plan/assignments, dated 11/15/2020 and 3/1/2021, included direction to the aide to shower the patient every visit, shave the patient every visit, assist the patient to dress every visit, apply lotion to the patient every visit and comb the patient's hair every visit. a. The home health aide visit notes, dated 1/12/2021 and 2/2, 2/4, 2/23 and 2/25/2021, lacked documentation of the aide shaving the patient. The same notes lacked documentation of the reason for omission of the task. b. The home health aide visit note, dated 2/2/2021, lacked documentation of the aide assisting the patient to dress. The same note lacked documentation of the reason for omission of the task. c. The home health aide visit notes, dated 2/2 and 2/9/2021, lacked documentation of the aide applying lotion. The same notes lacked documentation of the reason for omission of the task. d. The home health aide visit note, dated 2/2/2021, lacked documentation of the aide combing the patient's hair. The same note lacked documentation of the reason for omission of the task. 5. Patient #7 had a start of care date of 10/23/2020 and was discharged from home care services on 3/9/2021. Clinical record review revealed the following: a. The home health aide care plan/assignments, dated 2/10/2021, included direction to the aide to remove and apply compression stockings every visit. Applying compression stockings is an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plans of Care, dated 12/22/2020 to 2/19/2021 and 2/20/2021 to 4/20/2021, lacked physician approval for the home health aide to apply the compression stockings as an extension of nursing services. b. The home health aide care plan/assignment, dated 2/10/2021, included direction to the aide to remove and apply compression stockings every visit. The home health aide visit notes, dated 2/15, 2/18, 2/22, 2/25 and 2/20/2021 lacked documentation of the aide removing and applying the compression stockings as directed by the nurse. The same notes lacked documentation of the reason for omission of the task. The above stated findings for Patients #1, #2, #3, #5 and #7 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer for 1 of 3 sampled patients with requiring a transfer summary (Patient #1). The agency reported a current census of 16 patients. The agency reported 7 patients transferred to an inpatient facility in the previous 6 months. Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy, titled Medication Reconciliation and dated 3/2018, when a patient is transferred to another organization, the agency will send a copy of the patient's current medication list and document the communication. Patient #1 had a start of care date of 6/10/2010. Clinical record review revealed the following: The Plan of Care, dated 2/2/2021 to 4/2/2021, included documentation of the diagnosis of diabetes. The transfer to inpatient assessment, dated 2/14/2021, documented the patient was admitted to the hospital on 2/14/2021 for treatment of high blood sugars/diabetes. The patient remained hospitalized until return home on 2/18/2021. The clinical record lacked documentation of a transfer summary. The clinical record lacked evidence the agency sent a list of medications taken by the patient as required by agency policy. During agency staff interview on 3/10/2021 at 8:50 AM, the Administrator reported reviewing the patient's electronic clinical record and was unable to locate documentation of completion of a transfer summary for the 2/14/2021 hospitalization. The above stated findings for Patient #1 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.