Every finding on record at Lakeside Quality Home Health Care Inc

During the Recertification survey commenced on 10/19/2021 and concluded on 10/21/2021 at Lakeside Quality Home Health Care Inc., a Home Health Agency, Emergency Preparedness was reviewed. Lakeside Quality Home Health Care Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced Recertification survey was commenced on 10/19/2021 and concluded on 10/21/21 at Lakeside Quality Home Health Care Inc., Home Health Agency provider located at 109 S. Lake Avenue Pahokee, Florida. The Home Health Agency was not in compliance with 42 CFR Part 484 Subpart A-C, Conditions of Participation for Home Health Agencies.

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 record review and interview, the Home Health Agency (HHA) failed to follow the Physicians’ ordered Plan of Care (POC) for the frequency of SN (Skilled Nurse), Home Health Aide and Physical Therapy visits for 2 of 13 sampled patients (Patient #11 and #12). The findings included: 1. Review of the record reveals Patient #11 was re-admitted to the HHA’s services on 06/26/21 for the provision of Home Health Aide services. Review of the physician's order dated, 06/26/21 for Home Health Aide services documents 1 hour of personal care on Monday, Tuesday, Wednesday, Thursday, and Friday; 1 hour homemaker services on Monday, Tuesday, Thursday, Friday, and 2 hours of homemaker services on Wednesday. Further review reveals no evidence of Home Health Aide visit from 8/9/21-8/13/21 and there was no evidence of a Home Health Aide "missed visit" recorded in Patient #11’s records for these days. There was no evidence of whether the Home Health Aide's "missed visits" were reported to the patient's physician. On 10/20/21 at 2:38 PM during an interview, the DON (Director of Nursing) agreed with findings and stated that the staff had 7 days to turn in their "notes." 2. Review of the record reveals Patient #12 was admitted to the HHA’s services on 09/06/21 for the provision of Physical Therapy (PT) services. Review of the physician's order, dated 09/06/21 reveals documentation of PT visits 2 times a week for 6 weeks. Review of the patient's records for Week (3) which was 09/19-9/25/21 reveals only 1 PT visit was documented. Furthermore, the records for Week 4 which was 09/26-10/02/21, reveal only 1 visit was documented. Continued review reveals there was no PT "missed visit" document recorded in Patient #12’s records for 9/24 and 9/27/21. On 10/20/21 at 3:21 PM, a side-by-side review of Patient #12’s records and interview was conducted with the DON, who agreed with the findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency (HHA)'s Policies and Procedures, record review and interview, the HHA failed to ensure an accurate and complete record for 5 of 13 sampled patients as evidenced by the failure to include the Skilled Nursing, Physical Therapy and Home Health Aide visit notes as part of Patient #2, #4 and Patient #10’s record and the "missed visit" note as part of Patient #4's record; failure to ensure the Discharge Outcome and Assessment Information Set (OASIS) was complete and failure to provide evidence of whether "missed visits" were reported to the physician for Patient #11 and Patient #13 (Patient #2, #4, #10, #11 and #13). The findings included: 1. Review of the HHA's Policy and Procedure for "Clinical Notes/Initial Assessment" documents, "It is the policy of this agency that the following rules shall govern all caregiver’s notes: 1. The initial evaluation/assessment (including OASIS) assessment if applicable), to be done within forty eight (48) hours of the acceptance of a case, shall be due in the office as soon as possible but, in any case, no later than seventy two (72) hours from the time the case is accepted by this agency. 2. All progress ‘notes (RN’s, LPN’s, Therapist, HHA’s, CNA’s) shall be due in the office as follows: every week (by end of the day on Friday, no later than Monday at noon). 3. All caregivers (Skilled and non-skilled) are required to make scheduled visits to patients as prescribed in the plan of treatment established for that patient. 4. All nurses (Skilled and non-skilled) are required to make scheduled visits to patients as prescribed in the plan of treatment established for that patient. Notes on appropriate forms shall be made during the visits or as soon thereafter as possible but, in any case, not later than twenty four (24) hours after the visits is completed." Review of the record reveals Patient #2 was re- admitted to the HHA’s services on 09/23/21 for the provision of Skilled Nursing (SN) 3 times a week for 8 weeks. The Plan of Care for the certification period, 09/23/21 through 11/21/21 reveals no evidence of Skilled Nurse (SN )visit notes from 9/29/21, 10/1/21, 10/4/21, 10/6/21, and 10/8/21. Patient #2’s records reveal the SN notes for these days were “not started." On 10/19/21 at 12:51 PM, a side-by-side review of Patient #2’s records and interview was held with the Director of Nursing (DON) who agreed with the findings. 2. Review of the record reveals Patient #4 was admitted to the HHA’s services on 09/04/21 for the provision of Skilled Nursing, Home Health Aide and Physical Therapy services. Review of Patient #4’s records reveal the Home Health Aide visits were not documented in Patient #4’s records. The record for the Home Health Aide's visit, dated 09/09/21 reveals “not started." On 10/19/21 beginning at 2:57 PM, an interview was conducted with the Director of Nursing (DON) who stated that Patient #4 is Spanish speaking only, the Home Health Aide she assigned to Patient #4 did not speak Spanish and couldn’t work with the patient. Subsequent review of Patient #4's record reveals the "Physical Therapy Discharge Summary," dated 09/13/21 and the "Discharge OASIS" was incomplete and documented, “not started." Additionally, the Skilled Nursing Notes for SN visits on 09/13/21 was not made part of Patient #4's record. There was no evidence of SN visit for 09/17/21. On 10/19/21 at 3:01 PM, a side-by -side review of Patient #4’s records and interview was conducted with the DON who agreed with the findings and after the interview with the DON, on 10/19/21 at 3:01 PM, the Physical Therapy Discharge Summary was completed on 10/19/21. On 10/19/21 at 3:01 PM, during an interview, the DON stated that she was aware that Patient # 4 had a SN "missed visit" on 09/17/21, she stated “she did not document the missed visit in Patient #4’s record.” the DON stated she will document the missed visit today, 10/19/21. On 10/19/21 at 3:22 PM, the DON provided evidence of the SN missed visit which was documented today on 10/19/21. 3. Review of the record revealed Patient #10 was re-admitted to the HHA’s services on 08/15/21 for the provision of Skilled Nursing (SN) services. Review of Patient #10’s record reveals the SN visit was not documented in Patient #10’s records. The record for the SN visit, dated 10/07/21 documented “not started." On 10/20/21 at 1:37 PM, the DON agreed with the findings. 4. Review of the record revealed Patient #11 was re-admitted to the HHA’s services on 06/26/21 for the provision of Home Health Aide services. There was no evidence of a Home Health Aide visit from 8/9/21-8/13/21 and there was no evidence of a Home Health Aide "missed visit" recorded in Patient #11’s records for these days. There was no evidence of whether the Home Health Aide's "missed visits" were reported to the patient's physician. On 10/20/21 at 2:38 PM, during an interview, the DON agreed with findings and stated that the staff had 7 days to turn in their notes. 5. Review of the record reveals Patient #13 was admitted to the HHA’s services on 02/17/21 for the provision of SN and Physical Therapy services. Further review reveals there was no evidence of documentation that a "missed visit," on 03/26/21, was reported to the patient's physician. On 10/21/21 at 10:40 AM, during a side-by-side review of Patient #13’s record and interview, the DON agreed with findings.