Every finding on record at Kismet Sux, LLC

A Recertification Survey was conducted by the Department of Inspections and Appeals from 3/4/24 through 3/6/24. The recertification survey identified the home health agency was found to be operating in compliance with the following standard level Emergency Preparedness regulations.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan/policies, review of agency emergency preparedness training and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 2 of 4 sampled employees (Staff C and D). 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: According to the agency's policy titled Emergency Operations Plan, Training Program, dated August, 2023, the agency will provide emergency preparedness training at least every two years. Training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies that occurred in the last two years and during review of the emergency operations plan every two years. During an interview on 3/6/24 at 9:30 AM the Vice President of Operations stated contracted staff had not been provided training on the agency’s Emergency Preparedness policy. Review of the agency's emergency preparedness training revealed the following: 1. Staff C, Occupational Therapist, had a hire date of 7/31/18. The agency was unable to provide documentation of any emergency preparedness training. 2. Staff D, Physical Therapy Assistant, had a hire date of 4/23/17. The agency was unable to provide documentation of any emergency preparedness training. The above stated findings shared with the Administrator. The agency provided no further information prior to the end of the survey.

The Iowa Department of Inspections and Appeals conducted a Recertification Survey from 3/4/24 through 3/6/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency identified a census of 40 current patients.

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, staff and patient interview, and home observation visit, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment, and medications used by the patient for 2 out or 3 home observation visits. (Patient #2 and #3) Failure to maintain a complete and accurate Plan of Care, including necessary DME/Equipment, placed patients at risk of not receiving safe, effective and individualized care to meet each patients health care needs. 2. Patient #2 had a start of care date of 2/8/24. The POC, dated 2/8/24 to 4/7/24, included the following DME: brace/orthotics, elevated toilet seat, grab bars, Hoyer lift, oxygen, tub/shower bench, walker, wheelchair, oxygen/supplies, hand held shower and lift chair. During an observation home visit on 2/5/24 at 12:40 PM with Staff C, Occupational Therapist, the surveyor observed the patient to have a wheelchair ramp, wheelchair cushion and incontinent products. During an interview at the same observational home visit the patient's family stated the patient utilized the DME prior to the start of home health services. The agency failed to include all DME on the POC the patient required which included the wheelchair ramp, incontinent products and wheelchair cushion. The above stated findings shared with the Administrator. The agency provided no further information prior to the end of the survey. According to agency policy, titled Plan of Care - CMS 485 and Physician/Practitioner orders, dated December 2020, the individualized plan of care must include all medications and treatments. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan. Orders are verified when there are questions or discrepancies with orders. Physician/practitioner services will be provided by a licensed Doctor of Medicine, include prescribing medications and therapeutic regimens. 1. Patient #3, had a start of care date 6/13/23. Review of the clinical record, staff interview and patient interview revealed the following: The Plan of Care (POC), dated 2/8/24 to 4/7/24, included physicians orders for all medications and supplements. a. On 3/5/24 at 10:30 AM , during a home visit observation, Staff B, RN (Registered Nurse) set up medications in a daily planner for Patient #3. The POC included orders for: green tea extract 500 milligrams (mg) to be taken once a day, cinnamon 500 mg capsule to be taken once a day, advantage digestive lactose supplement 1-2 tablets once a day, and Vitamin A 2,400 mg once a day. These supplements were not available for medication set up in the home. b. During the same observation visit, Staff B, RN set up the following supplements; apple cider vinegar 450 mg tablet once a day, garlic 100mg capsules once a day and cod liver oil 500 mg once a day. The POC lacked orders for these supplements. c. During the same home observation visit, Staff B, RN , set up the supplement fish oil 500 mg once a day , POC orders for this supplement to be taken 500 mg twice a day. d. In an interview with Staff B, RN during the same home observation visit, She stated the patient didn't always pick up the supplements ordered at the store, and would frequently change his/her mind about what supplements he/she wanted to take. She also stated that she was working with the patient to decrease the number of supplements and had plans to discontinue supplements as he/she ran out. e. During an interview with Patient #3, also during the home observation visit, he/she stated was taking a whole tablet of the medication Trazadone, 100 mg (medication used to help with sleep and depression) at bedtime. The POC included the order for Trazadone 50 mg at bedtime. (equal to a half tablet) The Agency failed to obtain updated orders for supplements the RN was setting up in the home daily medication planner, and failed to obtain updated order for prescription medication patient self-administered. f. The POC, dated 2/8/24 - 4/7/24, included the following DME: cane, grab bars, walker, wheelchair, electric wheelchair and mediplanner. g. During an observation home visit on 2/5/24 at 10:30 AM, with Staff B, Registered Nurse, the surveyor observed the patient to have a shower/tub bench and no slip mats in the shower. During an interview at the same observational home visit the patient stated he/she received those items a while back through the insurance case manager so he could could still shower independently. The agency failed to include all DME on the POC the patient required which included the tub/shower bench and no slip bath mats in the shower.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 1 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patient #5). The agency reported 13 patients who received personal care assistance by a home health aide while also receiving skilled service provision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency's Home Health Aide Supervision, dated February 2022, if home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care and the written patient care instructions must make an onsite visit to the patient's home no less frequently than every 14 days. During an interview on 3/5/24 at 8:20 AM, the Administrator stated the home care aide supervision completed by the Registered nurse every 14 days if skilled services provided for the patient. On 4/22/19 at 1:34 PM, during an interview, Staff A, Administrator, reported the nurse documented supervision of the home health aide in the nursing assessment visit. Patient #5 had a start of care date of 12/8/23. The Plans of Care (POCs), dated 12/8/23 to 2/5/23 and 2/6/23 to 4/5/23, included physician orders for skilled nursing and home health aide services. Review of the clinical record included the following: a. The clinical record included home health aide services 2 times a week beginning 12/14/23. b. Documentation of home health aide supervision, dated 1/23/24. (5 weeks after the start of home health aide services). The agency failed to complete home health aide supervision every 14 days. The above information provided to the Administrator. The agency provided no further 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 and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 1 of 2 sampled patients with transfers/ discharges (Patient #7). 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, Discharge Summary, dated July 2021, the discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. During an interview on 3/6/24 at 10:50 AM the Administrator the transfer summary and discharge summary were only sent to the primary care physician and not sent to the admitting facility. Patient #2 had a start of care date of 10/11/22 and discharged from the agency on 12/11/23. Clinical record review revealed: a. An interim physician's order, dated 9/4/23, ordered to hold home health services on 9/3/23 until further notice due to the client in the hospital. b. A home health transfer summary completed by the Administrator, dated 9/4/23, included identification the patient transferred to the hospital and the summary sent to the primary care physician. c. An interim physician's order, dated 12/11/23, ordered to hold home health services due to the client admitted to the hospital on 12/9/23. d. A home health discharge summary completed by the Administrator, dated 12/11/23, included identification the patient transferred to the hospital and the summary was sent to the primary care physician. The agency failed to send the transfer summary and discharge summary to the receiving hospital. The above findings shared with the Administrator. The agency did not provide further information prior to the end of the survey.

A complaint investigation, dated 8/16/21 to 8/18/21, for complaint number 99104-C identified the following: The complaint related to 484.50 Patient Rights was unsubstantiated; The complaint related to 484.60 Careplanning, Coordination, Quality of Care was substantiated; The complaint related to 484.75 Skilled Professional Services was substantiated; The complaint related to 484.80 Home Health Aide Services was substantiated; The survey investigation found the agency to have the following standard level deficiencies for the Home Health Conditions of Participation.

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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8.) The agency reported a current census of 32 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with patient and caregiver education and training to facilitate timely discharge. Findings include: Review of the agency's policy dated December 2020, titled Care Planning Process, revealed all initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals. The initial care plan will include long range goals. The care plan update will reflect goal evaluation and goal resolution. Review of the agency's policy dated December 2020, titled Discharge Criteria and Planning, revealed guidelines for discharge of patients from the agency. Discharge planning begins at time of admission and will be reflected in the documentation. In an interview on 8/17/21 at 3:10 PM, Staff B, reported no discharge planning for long term patients is being done. When a patient decides to change services assistance is offered. 1. Patient #1 had a start of care date of 5/11/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 5/11/2021 to 7/9/2021 and 8/1/2021 to 9/29/2021, included physician orders for home skilled nurse services one time per week. b. In the same POCs Patient/Caregiver Education for Timely Discharge identifies; Not at this time. The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 2. Patient #4 had a start of care date of 2/2/21. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 2/2/2021 to 4/2/2021 and 7/10/2021 to 9/7/2021, included physician orders for home skilled nurse services one time per week. b. In the same POCs Patient/Caregiver Education for Timely Discharge identifies; No discharge planned at this time. The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 3. Patient #5 had a start of care date of 8/4/20 and discharge date of 7/7/21. Clinical record review revealed the POCs, dated 1/31/21 to 3/31/21, 4/1/21 to 5/30/21 and 5/31/21 to 7/29/21, identified a section titled "patient/caregiver education for timely discharge" that included documentation "not at this time". The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 4. Patient #6 had a start of care date of 8/5/11 and discharge date of 8/10/21. Clinical record review revealed the POCs, dated 2/13/21 to 4/13/21, 4/14/21 to 6/12/21 and 6/13/21 to 8/11/21, identified a section titled "patient/caregiver education for timely discharge" that included documentation "none at this time". The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 5. Patient #7 had a start of care date of 8/26/19 discharge date of 2/8/21. Clinical record review revealed the POCs, dated 8/20/20 to 10/18/20, 10/19/20 to 12/17/20 and 12/18/20 to 2/15/21, identified a section titled "patient/caregiver education for timely discharge" that included documentation "not at this time". The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 6. Patient #2 had a start of care date of 2/18/21. Clinical record review revealed the Plans of Care (POCs), dated 2/18/21 to 4/18/21, 4/19/21 to 6/17/21 and 6/18/21 to 8/16/21, identified a section titled "patient/caregiver education for timely discharge" that included documentation "not at this time". The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 7. Patient #3 had a start of care date of 5/4/21. Clinical record review revealed the POCs, dated 5/4/21 to 7/2/21 and 7/3/21 to 8/31/21, identified a section titled "patient/caregiver education for timely discharge" that included documentation "no discharge planned at this time". The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. 8. Patient #8 had a start of care date of 8/25/2020 and a discharge date of 2/18/21. Clinical record review revealed the POCs, dated 8/25/2020 to 10/23/2020, 10/24/2020 to 12/22/2020 and 12/23/2020 to 2/20/21, identified a section titled "patient/caregiver education for timely discharge" that included documentation "no discharge planned at this time". The agency failed to ensure the plan of care included patient and caregiver education and training to facilitate timely discharge. The Administrator received the above findings and agency staff provided no further 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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 3 of 8 sampled patients (Patients #3, #4 and #7) with a skilled nursing service. The agency reported a current census of 32 patients. Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. Findings include: Review of the agency's policy, titled Care Planning Process, dated December 2020, identified in order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process. Initial care plan which is developed and implemented with physician, demonstrates problems (diagnoses), interventions (physician orders) and long range goals. Physician supplemental orders may also be used to update the care plan. 1. Patient #3 had a start of care date of 5/4/21. Clinical record review revealed: a. The POCs, dated 5/4/21 to 7/2/21, included a physician order for skilled nursing services to provide wound care one time per week. b. The POC, dated 7/3/21 to 8/31/21, included a physician order for skilled nursing services to assess integumentary system (skin). c. The comprehensive assessment completed at the start of care, dated 5/4/21, included documentation of a left breast skin lesion with measurements of length and width but lacked depth measurement. d. The skilled nursing visit note, dated 6/1/21, included documentation left breast incision/stitches areas reddened, mild serosanguinous drainage noted but lacked measurement of the incision. e. The skilled nursing visit note, dated 6/8/21 and 6/15/21, included documentation left breast wound bed reddened, scant serosanguinous drainage noted but lacked wound measurements. f. The skilled nursing visit note, dated 6/21/21 and 7/13/21, included documentation left breast wound bed dark pink, scant serosanguinous drainage noted but lacked wound measurements. g. The comprehensive assessment completed at the time of recertification, dated 6/29/21, included documentation no wound care provided, but lacked documentation of wound measurements or the wound had resolved. h. The skilled nursing visit note, dated 7/6/21, included documentation left breast wound bed dark pink, scant drainage, appears healing but lacked wound measurements. i. The skilled nursing visit note, dated 7/20/21, included documentation left breast wound bed dry, dark pink, partially scabbed but lacked wound measurements. During an interview on 8/17/21 at 3:03 PM, Staff B, Registered Nurse (RN), reported wound measurements are documented weekly and include length, width and depth. 2. Patient #7 had a start of care date of 8/26/19 and discharge date of 2/8/21. Review of the clinical record revealed the following: a. The POC, dated 12/18/20 to 2/15/21, included physician orders for the skilled nurse to notify the physician for weight gain or loss of 5 pounds in 1 week. b. The skilled nursing note, dated 12/31/21, identified the patient had a weight loss of 14 pounds in 1 week. On 1/18/21 the patient had a weight gain of 7 pounds and on 1/25/21 a weight loss of 9 pounds in 1 week. The clinical record lacked documentation the physician was notified of the weight gain and loss. 3. Patient #4 had a start of care date of 2/2/21. Review of the clinical record revealed the following: a. The Plans of Care (POC's), dated 6/2/21 to 7/31/21 and 8/1/2021 to 9/29/2021, included physician orders for the skilled nurse to provide diabetic education/teaching and to notify the physician of blood sugars 100. b. The skilled nursing intervention notes dated 6/15/21, 6/22, 7/6, 7/13, 7/20, 7/27, 8/3 and 8/17/21 lacked documentation of diabetic education/teaching. c. The skilled nursing intervention notes dated 6/22/21, 7/13, 7/20 and 8/17/21 recorded bloods sugars > 200. d. The clinical record lacked documentation the physician was notified of blood sugars > 200. In an interview on 8/17/21 at 3:00 PM with Staff B, she reported the diabetic education is documented in the nursing notes. The physician notification of blood glucose is found in the communication notes or the agency alerts. The Administrator received the above findings and agency staff provided no further 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 clinical record review, agency policy review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed in writing by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patients #3 and #8). The agency reported a current census of 32 patients at the time of the survey. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: Review of the agency's policy, titled Home Health Aide Documentation, dated December 2020, identified documentation of the care performed by the home health aide on each visit, the home heath aide will document services rendered to the patient on the appropriate home health aide charting form as directed in the aide care plan/assignment sheet. During an interview on 8/18/21 at 8:25 AM, the Administrator reported a task on the aide assignment that is marked "as needed" should be addressed by the aide each visit. If two bath types are marked on the aide assignment, the type completed is checked and the type not completed is marked as not applicable or refused. 1. Patient #3 had a start of care date of 5/4/21. Clinical record review revealed: a. The aide plans of care, dated 6/11/21 and 7/1/21, included the tasks shower, partial sponge bath, apply Remedy Cream (antifungal cream), and shave, for the aide to complete. b. The home health aide visit note, dated 6/14/21, lacked documentation the aide completed the tasks Remedy Cream and shave or a reason why the tasks were not completed. c. The home health aide visit note, dated 7/19/21, lacked documentation the aide completed the task shower or a reason why the task was not completed. d. The home health aide visit notes, dated 8/2/21 and 8/9/21, included documentation the aide completed a bed bath per patient request but lacked documentation the home health aide contacted the supervising nurse for instruction to complete a bed bath. The tasks shower or partial sponge bath lacked a reason why the tasks were not completed. During an interview on 8/18/21 at 11:20 AM, the Administrator reported complete sponge bath/bed bath is different from a partial sponge bath and the home health aide should not have completed that without direction from a registered nurse. The agency failed to ensure the home health aide provided care according to the aide plan of care. 2. Patient #8 had a start of care date of 8/25/2020 and a discharge date of 2/18/21. Clinical record review revealed: a. The aide plans of care, dated 10/20/2020, included the tasks Periwash as needed and partial sponge bath, for the aide to complete. b. The home health aide visit notes, dated 11/24, 11/27, 12/1,12/4, 12/11, 12/15, 12/18, 12/22, 12/29/2020, 1/8, and 1/12/21, lacked documentation Periwash was used or a reason why the task was not completed. c. The home health aide visit notes, dated 12/8/2020 and 1/5/21, lacked documentation the tasks partial sponge bath and Periwash were completed or a reason why the tasks were not completed. The agency failed to ensure the home health aide provided care according to the aide plan of care. The Administrator received the above findings and agency staff provided no further 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 discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 1 of 4 sampled patients with discharges (Patient #6). 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 Discharge Summary, dated July 2021, a discharge summary form will be completed by the skilled nurse, medical social worker or therapist. A discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.During an interview on 8/17/21 at 11:30 AM the Administrator stated the agency did not complete a discharge summary because the patient did not require an OASIS (Outcome and Assessment information Set) assessment completed which would have generated a discharge summary. Patient #5 had a start of care date of 8/5/11 and discharge date of of 8/10/21. The patient's clinical record included the following: a. The comprehensive assessment, dated 8/10/21, identified the patient discharged form home health services effective 8/10/21. b. The patient's clinical record lacked documentation of a completed discharge summary. The above findings were reviewed with the Administrator. The agency provided no further information prior to the end of the survey.

The recertification survey, conducted 3/1/2021 through 3/3/2021 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 6 of 6 contracted therapy staff consistent with their expected roles in the event of an emergency/disaster. The agency reported 6 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 3/3/2021 at 12:45 PM, the Administrator reported she had not been having any contracted therapy staff trained to the agency's emergency preparedness plan or during any of the training 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, 4/8/2020 and 6/6/2020. 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 C, contracted Occupational Therapist (OT); Staff D, contracted Physical Therapist (PT); Staff D, PT; Staff E, PT; Staff F, OT; Staff G, OT; or Staff H, Speech Therapist. The agency did not assure initial training for the agency's emergency preparedness/disaster plan to assure each contracted employee's understanding of the plan was completed 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 with a recertification survey from 3/1/21 through 3/3/21 . 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 and agency policy review, the agency failed to complete a review of all required components of the drug regimen review and accurately identify actual or potential issues related to the drug regimen review as part of the update to the comprehensive assessment for 5 of 7 sampled patients (Patients #1, #2, #3, #6 and #7). The agency reported a current patient census of 42 patients. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns 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 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 3/1/2021 at 2:45 PM, the Clinical Manager reported the clinicians assess reconcile all of the medications taken by the patient and document 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 5/1/2012. Clinical record review revealed the following: a. The Plans of Care, dated 9/16/2020 to 11/14/2020, 11/15/2020 to 1/13/2021 and 1/14/2021 to 3/14/2021, included physician orders for docusate sodium (a stool softener); Miralax (a laxative with stool softener) and Fiberlax (a natural laxative). b. The communication notes, dated 9/15/2020, 11/15/2020 and 1/12/2021, included documentation of drug regimen reviews completed by the registered nurse. All three of the drug regimen reviews lacked identification of the duplicate bowel medications taken to prevent constipation when performing the drug regimen reviews. 2. Patient #2 had a start of care date of 1/8/2020. Clinical record review revealed the following: a. The Plans of Care, dated 9/4/2020 to 11/2/2020, 11/3/2020 to 1/1/2021 and 1/2/2021 to 3/2/2021, included physician orders for docusate sodium (a stool softener) and Miralax (a laxative with stool softener); gabapentin, Tylenol with Codeine and Fentanyl, all pain medications; and amlodipine and furosemide, both taken by the patient to assist lower blood pressure. b. The communication notes, dated 9/2/2020, 11/2/2020 and 12/31/2020, included documentation of drug regimen reviews completed by the registered nurse. All three of the drug regimen reviews lacked identification of any duplicate medications. The registered nurse failed to identify the duplicate bowel medications taken to prevent constipation, duplicate pain medications and duplicate blood pressure medications when performing the drug regimen reviews. 3. Patient #3 had a start of care date of 1/30/2021. Clinical record review revealed the following: a. The Plan of Care, dated 1/30/2021 to 3/30/2021, included physician orders for furosemide and spironlactone, both diuretics. b. The communication note, dated 2/3/2021, included documentation of drug regimen reviews completed by the registered nurse. The review lacked documentation of identification of any duplicate medications. The drug regimen review lacked identification of the duplicate diuretics. 4. Patient #6 had a start of care date of 11/20/2020 and a discharge date of 1/12/2021. Clinical record review revealed the following: a. The Plan of Care, dated 11/20/2020 to 1/18/2021, included physician orders for Percocet, Tramadol and Advil, all pain medications. b. The communication notes, dated 11/25/2020 and 1/14/2021, included documentation of drug regimen review completed by the registered nurse. Both of the reviews lacked documentation of identification of any duplicate medications. The drug regimen reviews lacked identification of the duplicate pain medications. 5. Patient #7 had a start of care date of 9/4/2020 and a discharge date of 10/12/2020. Clinical record review revealed the following: a. The Plan of Care, dated 9/4/2020 to 11/2/2020, included physician orders for amlodipine and metoprolol, both medications taken to lower blood pressure; and furosemide and isosorbide, both diuretics. b. The communication notes, dated 9/9/2020 and 10/13/2020, included documentation of drug regimen reviews completed by the registered nurse. Both of the review lacked documentation of identification of any duplicate medications. The drug regimen reviews lacked identification of the duplicate blood pressure medications and diuretics. The above stated findings for Patients #1, #2, #3, #6 and #7 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 and agency policy review, 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 2 of 3 sampled patients requiring a recertification assessment (Patients #4 and #5). The agency reported a census of 42 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 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 #4 had a start of care date of 5/15/2020. Clinical record revealed the following: a. The Plans of Care, dated 7/14/2020 to 9/11/2020 and 9/12/2020 to 11/10/2020, included physician orders for home health aide services for personal care assistance with supervision by a registered nurse every 60 days. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 9/11/2020 (day 60 of the certification period) but was not completed until 9/13/2020, 2 days into the new certification period. c. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 9/13/2020. The certification period ended on 9/11/2020. The assessment with accompanying drug regimen review was not completed by day 60 as required by regulation and agency policy. 2. Patient #5 had a start of care date of 12/30/2020. Clinical record revealed the following: a. The Plans of Care, dated 12/30/2020 to 2/27/2021 and 2/28/2021 to 4/28/2021, included physician orders for home health aide services for personal care assistance with supervision by a registered nurse every 60 days. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 2/26/2021 (day 59 of the certification period) but was not completed until 2/28/2021, 1 day into the new certification period. c. The drug regimen review to accompany the above stated update to the comprehensive assessment at the time of recertification was dated 2/28/2021. The certification period ended on 2/27/2021. 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 #4 and #5 were reviewed with the Administrator, the Clinical Manager and Staff A, Registered Nurse. 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 agency policy review and clinical record review, 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 1 of 1 sampled patients requiring a resumption of care assessment (Patient #2). The agency provided services to 42 patients at the time of the survey and performed 8 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 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. Patient #2 had a start of care date of 1/8/2020. Clinical record review revealed the following: a. The update to the comprehensive assessment at the time of resumption of care, dated 1/15/2020, documented the patient was discharged from the hospital on 1/15/2020. The nurse initiated the update to the assessment on 1/15/2020 but did not complete the accompanying medication assessment (drug regimen review) until 1/19/2020, 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. The above stated findings for Patient #2 were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 2 sampled patients with home visits for medication set up observation (Patients #1 and #2). The agency reported a current patient census of 42 patients. Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Medication Reconciliation and dated 3/2018, the agency will initially reconcile patient medications at the time of admission and reconcile on an ongoing basis as needed. 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 5/1/2012. Review of the clinical record, home visit observation and associated agency staff interviews revealed the following: a. The Plans of Care, dated 9/16/2020 to 11/14/2020, 11/15/2020 to 1/13/2021 and 1/14/2021 to 3/14/2021, included physician's orders for the registered nurse (RN) to visit the patient once weekly to monitor the patient's health status and to set up the patient's medications in a medication planner. The Plans included orders for the patient to take Pantoprazole 40 milligrams twice daily. b. During the home visit to Patient #1's home while accompanied by Staff A, RN on 3/2/2021 at 9:30 AM, the surveyor observed the RN set up the patient's medications in a weekly medication planner. During the medication set up, Staff A, RN, did not set up the patient's Pantoprazole. c. During agency staff interview while in the patient's home on 3/2/2021, Staff A, RN, reported she needed to clarify whether the patient should still be taking the Pantoprazole while taking the Dexilant ECC. The nurse reported a plan to contact the physician to get clarification. d. The Patient Medication List, dated as printed on 3/1/2021, included Dexilant ECC 60 milligrams every day with a start date of 10/6/2020. The List continued to include Pantoprozole 40 milligrams twice daily with a start date of 9/15/2020. e. During agency staff interview on 3/2/2021 at 3:55 PM, Staff A, RN, reported she had not been setting up the Pantoprazole up in the patient's planners since the patient began taking Dexilant in October 2020. Staff A reported she contacted the physician after the home visit earlier in the morning and the physician gave an order to discontinue the Pantoprazole. The RN reported sending the verbal order for signature this afternoon. The nurse did not fill the patient's medication planner with Pantoprazole as ordered by the physician since 10/6/2020. 2. Patient #2 had a start of care date of 1/8/2020. Review of the clinical record, home visit observation and associated agency staff interviews revealed the following: a. The Plan of Care, dated 1/2/2021 to 3/2/2021, included physician's orders for Vitamin C 100 milligrams daily. b. The Patient Medication List, dated as printed on 3/1/2021, included Vitamin C 100 milligrams every day with a start date of 1/8/2020. c. During the home visit to Patient #2's home while accompanied by Staff B, RN, on 3/2/2021 at 10:45 AM, the surveyor observed the RN set up the patient's medications in a weekly medication planner. During the medication set up, Staff B, RN, set up the planner with Vitamin C 500 milligrams tablets 1 daily. The 100 count bottle of 500 milligram tablets, purchased by the patient over-the-counter, was approximately half full. d. During agency staff interview on 3/2/2021 while in the patient's home, Staff B, RN, reported she had not noted the difference between the physician ordered dosage of Vitamin C and the dosage of tablets in the patient's bottle. The nurse did not fill the patient's medication planner with the correct dose of Vitamin C during the home visit. The above stated findings for Patients #1 and #2 were reviewed with the Administrator and the Clinical Manager. 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 3 of 4 sampled patients receiving home health aide services (Patients #2, #4 and #5). The agency reported a census of 42 patients, including 30 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 1/8/2020. The Plans of Care, dated 9/4/2020 to 11/2/2020, 11/3/2020 to 1/1/2021 and 1/2/2021 to 3/2/2021, included physician orders for skilled nursing services and home health aide services. Clinical record review revealed: a. The home health aide assignment/care plans, dated 10/21/2020, 12/16/20 and 2/10/2021, directed the aides to perform both a shower and a sponge bath. The care plans lacked any direction for the aide to determine when to perform the shower and when to perform a sponge bath. On 3/2/2021 at 10:45 AM, the surveyor accompanied Staff B, RN, to the patient's home. Patient interview occurring during the home visit revealed Patient #2 reported a preference to have a shower on Mondays and Fridays and a sponge bath on Wednesdays to avoid overly dry skin. The RN did not direct the aide with specific bathing instructions based on the patient's preferences. b. The home health aide assignment/care plans, dated 12/16/2020 and 2/10/2021, added the task of applying and removing the patient's compression stockings "as needed" to the care plan, thereby allowing the aide to decide whether to apply or remove the stockings or not. The assignment required the home health aide to assess to determine when the application or removal of the compression stockings was required, which exceeds the scope of practice of a home health aide. Surveyor observation during the home visit revealed the patient did not have compression stockings on. Patient interview occurring during the home visit revealed Patient #2 reported he/she did not wear the stockings any longer. Agency staff interview during the home visit revealed Staff B, RN, reported the patient sat in a recliner with his/her legs dependent (down) a lot and compression stockings were ordered for the patient during the last hospitalization. Staff B, RN, reported the patient should have had the compression stockings on. c. The home health aide assignment/care plans, dated 10/21/2020, 12/16/20 and 2/10/2021, directed the aides to apply powder to the patient's abdominal fold if red. The care plan directions did not identify the type of powder the aide was to apply. On 3/2/2021 at 10:45 AM, the surveyor accompanied Staff B, RN, to the patient's home. Agency staff interview during the home visit revealed Staff B, RN, assigned the aides to apply Nystatin powder, a medicated powder ordered by physician prescription to the abdominal fold if red. The careplan lacked specific directions to the aides to follow, including the name of the medicated powder. 2. Patient #4 had a start of date of 5/15/2020. The Plans of Care, dated 9/12/2020 to 11/10/2020, 11/11/2020 to 1/9/2021 and 1/10/2021 to 3/10/2021, included physician orders for home health aide services without the provision of skilled services. Clinical record review revealed: The home health aide assignment/care plans, dated 9/11/2020, 11/6/2020 and 1/5/2021, to apply Nystatin, a medicated powder ordered by physician prescription, "to reddened areas as needed". The direction to the aides did not include the body parts the aide could apply when red. The task was assigned "as needed" to the care plan, thereby allowing the aide to decide whether to apply or not apply the powder. The assignment required the home health aide to assess to determine when the application was required, which exceeds the scope of practice of a home health aide. 3. Patient #5 had a start of date of 12/30/2020. The Plans of Care, dated 12/30/2020 to 2/27/2021 and 2/28/2021 to 4/28/2021, included physician orders for home health aide services without the provision of skilled services. Clinical record review revealed: The home health aide assignment/care plans, dated 10/21/2020, 12/16/20 and 2/10/2021, directed the aides to perform both a shower and a sponge bath. The care plans lacked any direction for the aide to determine when to perform the shower and when to perform a sponge bath. The RN did not direct the aide with specific bathing instructions based on the patient's preferences. The above findings for Patients #2, #4 and #5 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.