Every finding on record at Lataurus Johnson

A recertification survey was initiated on 07/11/2022. The census was 0. No deficiencies were cited.

A recertification survey was initiated on 07/11/2022. The census was 0. Abbreviations/Acronyms: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nurses (Supervising Nurse) ADON-Assistant Director of Nurses (Alternate Supervising Nurse) Registered Nurse (RN) Licensed Vocational Nurse (LVN) NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care HHA's- Home Health Agencies PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement OASIS -outcome and assessment information set SN- Skilled Nursing CMS- Center for Medicare and Medicaid Services

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 8) of two inactive patient records reviewed and who required the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate planning in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 6: Record review of the hard copy clinical record for Patient # 6 revealed a POC with a SOC date of 08/01/2017. The POC had a certification period 07/11/2021 to 09/08/2021 and a principal diagnosis of hypertensive heart disease. The POC was signed by the DON and dated 07/10/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. Patient # 6's record included a discharge order signed by the DON and dated 07/31/2021. The discharge order listed the reason for discharge as “Changed Payor Source.” The record also included a discharge OASIS dated 07/31/2021 and signed by the DON. The OASIS listed the discharge date as 07/31/2021. Patient # 6's record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 07/31/2021. The record did not include a written NOMNC. Clinical Record # 8: Record review of the hard copy clinical record for Patient # 8 revealed a POC with a SOC date of 05/27/2019. The POC had a certification period 09/13/2021 to 11/11/2021 and a principal diagnosis of encounter for colostomy care. The POC was signed by the DON and dated 09/11/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The record also included a discharge OASIS signed by the DON and dated 11/08/2021. The OASIS listed the discharge reason as family request and discharge date as 11/08/2021. Patient # 8's record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 11/08/2021. The record did not include a written NOMNC. In an interview with the Alt Adm on 07/15/2022 at 11:02 a.m., the surveyor discussed the above findings of why the agency had not provided proper written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 8. The Alt Adm replied, “I don’t think the nurses are aware of how to use the notice when the patient is discharged back into the community.” The surveyor also discussed how not providing proper written notice to the agency’s patients, of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care could adversely affect them. The Alt Adm stated that she did not know and “I don’t have any more scenarios.” Agency policy titled “Discharge Planning” dated 3Q/2020 read in part: “…PROCEDURE…IX...Notice of Medicare Non-Coverage…is issued per CMS regulations… XV.NOMNC…A…B…C…D…The NOMNC is issued per CMS regulations.”

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 and interview, the agency failed to ensure that the individualized plan of care included 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, in five (Records # 6 through # 10) of five clinical records reviewed. The failure placed the patients at risk to not have the necessary care and interventions in place to address the underlying risk factors to prevent emergency department visits and hospital re-admissions. FINDINGS INCLUDED: Clinical Record # 6: Record review of the hard copy clinical record for Patient # 6 revealed a POC with a SOC date of 08/01/2017. The POC had a certification period 07/11/2021 to 09/08/2021 and a principal diagnosis of hypertensive heart disease. The POC was signed by the DON and dated 07/10/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The POC did not include a description of Patient # 6's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Clinical Record # 7: Record review of the hard copy clinical record for Patient # 7 revealed a POC with a SOC date of 11/16/2020. The POC had a certification period 07/14/2021 to 09/11/2021 and a principal diagnosis of heart disease of native arteries. The POC was signed by the DON and dated 07/13/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The POC did not include a description of Patient # 7's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Clinical Record # 8: Record review of the hard copy clinical record for Patient # 8 revealed a POC with a SOC date of 05/27/2019. The POC had a certification period 09/13/2021 to 11/11/2021 and a principal diagnosis of encounter for colostomy care. The POC was signed by the DON and dated 09/11/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The POC did not include a description of Patient # 8's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Clinical Record # 9: Record review of the hard copy clinical record for Patient # 9 revealed a POC with a SOC date of 06/04/2020. The POC had a certification period 09/27/2021 to 11/25/2021 and a principal diagnosis of peripheral vascular disease. The POC was signed by the DON and dated 09/24/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The POC did not include a description of Patient # 9's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Clinical Record # 10: Record review of the hard copy clinical record for Patient # 10 revealed a POC with a SOC date of 12/07/2016. The POC had a certification period 11/11/2021 to 01/09/2022 and a principal diagnosis of peripheral vascular disease. The POC was signed by the DON and dated 11/10/2021. The POC contained an order for SN visits one time per week for eight weeks and three as needed visits. The POC did not include a description of Patient # 10's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. During an interview on 07/15/2022 with the Alt Adm at 10:41 a.m., the surveyor discussed the above findings of why the POC's for Patients # 6 through # 10 did not include 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. The Alt Adm replied, “I can’t say that the RN(s) were aware of the requirement.” The surveyor also discussed how not including 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 could adversely affect the agency’s patients. The Alt Adm stated that was neglect on the RN(s) part about documentation or follow-through or follow-up and “That could affect the patient care. It could.” Review of agency policy titled "Plan of Care" dated 3Q2020, read in part "...PURPOSE: To ensure quality care and adherence to regulatory requirements and standards of care…Procedure ...VII. The individualized POC must include the following...L. 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..." Review of Agency policy titled “Care Planning Process…” dated 3Q2020 read in part: “…PROCEDURE…III. Content of the comprehensive assessment. The comprehensive assessment…must include at a minimum, the following information…V. The assessing clinician…creates the Individualized Plan of Care (POC) that specifies…L. 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...”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, in one of one agency QAPI program, the agency failed to conduct and document PIP(s) for the calendar years 2019, 2020 and 2021 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. The failure could also place the agency’s patients’ health and safety at risk if the agency missed health and safety concerns with service delivery. FINDINGS INCLUDED: During the entrance conference on 07/11/2022 at 10:45 a.m., the surveyor requested all agency QAPI documents/reports/manuals. The Adm stated that the Alt Adm had the records at her home, and she would bring the records after she completed an appointment and “She is on the way.” At approximately 12:00 p.m., the Alt Adm arrived at the agency. The surveyor requested the QAPI records. The Alt Adm stated that the DON had the records at her home. She also stated that the DON was working at another job and would get off at 4:00 p.m. to bring the records to the agency. At approximately 3:00 p.m., the Alt Adm provided a QAPI binder. The Alt Adm stated that the binder contained QAPI documents for 2019 to 2022 and that the DON had the QAPI documents for the remainder of 2022. Record review of the binder showed that it contained “Quality Assessment/Performance Improvement/Utilization Review Quarterly Reports, Infection Control Logs, Infection Control Reports, and Quarterly Transmittal Reports [Coversheets].” The quarterly QAPI reports were as listed: 2nd Quarter 2021 dated 07/02/2021; 1st Quarter 2021 dated 04/02/2021; 4th Quarter 2020 undated; 3rd Quarter 2020 dated 10/02/2020; 1st Quarter 2020 undated; 4th Quarter 2019 undated and 3rd Quarter 2019 undated. The binder did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements for the years 2019, 2020 and 2021. During an interview on 07/15/2022 at 10:19 a.m., with the Alt Adm, the surveyor discussed the above findings of why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2019, 2020 and 2021. The Adm stated that the agency “started that in 2021.” The Adm provided documents titled “QAPI Action Plan and QAPI Monitoring” and stated that “that is normally how we address problems that we find.” Review of the Action plan revealed that it was dated 04/04/2022 and described an action plan to improve monitoring of expired car insurance. Review of the QAPI Monitoring revealed that it listed monitoring in May, June, and July 2022 for expired car insurance. The action plan and QAPI monitoring documents did not reveal that the agency had conducted PIP(s) per federal regulatory requirements, for the years 2019, 2020 and 2021. The surveyor also discussed how could the agency’s patients be negatively impacted because the agency did not conduct performance improvement project in accordance with the federal regulatory requirements. The Alt Adm stated that the agency would probably “miss something.” Review of agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT-TEXAS" dated 3Q2020 read in part: “…PROGRAM ACTIVITIES…Performance Improvement Projects I. The number and scope of distinct PI projects conducted annually must reflect the scope, complexity, and past performance of the Agency's services and operations…II. The Agency must document the quality improvement projects undertaken, reasons for conducting these projects, and the measurable progress achieved…”

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 record review and interview, the agency failed to ensure that the agency’s inactive clinical records contained all clinical notes in three (Patients # 7, 8 and 9) of five clinical records reviewed. The failure could place the patients at risk to receive inadequate care and services and lack of continuity of care if the clinical notes were not completed timely during the patients’ active status. The failure prevented the surveyor from determining compliance with the agency’s skilled nursing service delivery (for the certification period reviewed). FINDINGS INCLUDED: During the entrance conference on 07/11/2022 at 10:45 a.m., the Adm stated that the agency’s electronic system (Identifier 300) had not been serving the agency since 06/30/2022. The Adm stated that the agency had hard copy patient records, but some of the “notes” had not been printed prior to being locked out of the electronic system. During an interview on 07/11/2022 at approximately 1:00 p.m., the Alt Adm stated that the agency had been locked out of Identifier 300, since 06/30/2022. The Alt Adm stated the agency had not had access to the agency’s inactive records since 06/30/2022. She stated that the agency would not be able to provide some copies of the patients’ records (like skilled nurses notes). Clinical Record # 7: Record review of the hard copy clinical record for Patient # 7 revealed a POC with a SOC date of 11/16/2020. The POC had a certification period 07/14/2021 to 09/11/2021 and a principal diagnosis of heart disease of native arteries. The POC was signed by the DON and dated 07/13/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. Review of SN notes provided by the Adm on 07/11/22 and 07/13/22 revealed the following for the certification period of 07/14/2021 to 09/11/2021: a missed visit note dated 07/14/2021 and a SN note dated 07/18/2021. Further review of the SN notes revealed that four of the projected seven (Patient # 7 was discharged on 08/24/2021) SN visits that were ordered on the POC were not available for review. Clinical Record # 8: Record review of the hard copy clinical record for Patient # 8 revealed a POC with a SOC date of 05/27/2019. The POC had a certification period 09/13/2021 to 11/11/2021 and a principal diagnosis of encounter for colostomy care. The POC was signed by the DON and dated 09/11/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. Review of SN notes provided by the Adm on 07/11/22 and 07/13/22 revealed the following for the certification period of 09/13/2021 to 11/11/2021: nine of the projected nine SN visits that were ordered on the POC were not available for review. Clinical Record # 9: Record review of the hard copy clinical record for Patient # 9 revealed a POC with a SOC date of 06/04/2020. The POC had a certification period 09/27/2021 to 11/25/2021 and a principal diagnosis of peripheral vascular disease. The POC was signed by the DON and dated 09/24/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. Review of SN notes provided by the Adm on 07/11/22 and 07/13/22 revealed the following for the certification period of 09/27/2021 to 11/25/2021: nine of the projected nine SN visits that were ordered on the POC were not available for review. During an interview with the Alt Adm at 10:41 a.m., the surveyor discussed the above findings of why the inactive clinical records did not contain all clinical notes for Patients # 7, 8 and 9. The Alt Adm stated that the agency was having problems with the computers. She also replied, “We fixed it. I don’t know why the notes were not there.” The surveyor also discussed how not having clinical notes in the patients’ clinical records could adversely affect the agency’s patients. The Alt Adm stated that it wouldn’t have because “we figured it out.” Agency policy titled “Clinical Note” dated 3Q/2020 read in part “…PROCEDURE…X. Clinical notes are incorporated into the client record on a timely basis but no later than fourteen business days after submitted…”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all entries to patients’ clinical records were completed, appropriately authenticated (signature and title of primary author), dated, and timed in three (Patients # 8, # 9 and # 10) of five inactive licensed and certified patients whose clinical records were reviewed. The failure placed the patients at risk of receiving inadequate service delivery and for their needs to be unmet because a primary author had not reviewed and approved the entries to the clinical record. The failure caused one patient to not have physician oversight of the plan of care. FINDINGS INCLUDED: Patient # 8: Clinical Record # 8: Record review of the hard copy clinical record for Patient # 8 revealed a POC with a SOC date of 05/27/2019. The POC had a certification period 09/13/2021 to 11/11/2021 and a principal diagnosis of encounter for colostomy care. The POC was signed by the DON and dated 09/11/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The clinical record for Patient # 8 revealed that the POC for certification period 09/13/2021 to 11/11/2021 was not signed or dated by Client # 8’s Physician (Identifier 800). The clinical record also contained a physician’s order, dated 11/08/2021, that was not signed or dated by Identifier 800. Patient # 9: Clinical Record # 9: Record review of the hard copy clinical record for Patient # 9 revealed a POC with a SOC date of 06/04/2020. The POC had a certification period 09/27/2021 to 11/25/2021 and a principal diagnosis of peripheral vascular disease. The POC was signed by the DON and dated 09/24/2021. The POC contained an order for SN visits one time per week for nine weeks and three as needed visits. The clinical record for Patient # 9 revealed that the Discharge OASIS dated 11/24/2021 was not signed by the RN assessor, the DON. The clinical record also contained a physician’s order, dated 11/08/2021, that was not signed or dated by Identifier 800. Patient # 10: Clinical Record # 10: Record review of the hard copy clinical record for Patient # 10 revealed a POC with a SOC date of 12/07/2016. The POC had a certification period 11/11/2021 to 01/09/2022 and a principal diagnosis of peripheral vascular disease. The POC was signed by the DON and dated 11/10/2021. The POC contained an order for SN visits one time per week for eight weeks and three as needed visits. The Clinical record contained a SN visit note dated 11/29/2021 that listed the DON as the “assessor.” The SN note was not signed by the DON. The clinical record for Patient # 10 revealed that the Discharge OASIS dated 11/24/2021 was not signed by the RN assessor, the DON. The clinical record also contained a physician’s order, dated 11/29/2021, that was not signed or dated by Identifier 900 or the DON. During an interview with the Alt Adm on 07/15/2022 at 11:02 a.m.., the surveyor discussed the above findings of why Patients # 8, 9 and 10’ s clinical records contained records and entries that were not appropriately authenticated, in accordance with regulatory requirements. The Alt Adm replied, “I can’t answer that. Oversight.” The surveyor also discussed how not ensuring that all entries to patients’ clinical records were completed, appropriately authenticated with the signature and title of primary author, dated, and timed could adversely affect the agency’s patients. The Alt Adm stated that she did not know how the agency’s patients could be adversely affected.