Every finding on record at Lee County Auditor

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 8/26/24 through 8/29/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 8/26/24 through 8/29/24 and found the home health agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 42 patients at the time of the survey.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on agency policy review, and clinical record review, the agency failed to ensure accurate completion of all pertinent components of the start of care comprehensive assessment within the regulated time frame for 1 of 7 sampled patients. (Patient #7) Failure to accurately and thoroughly complete the start 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. According to the policy, titled Clinical Records, dated February 2023, assessments must be completed and confirmed with an electronic signature within the specific regulatory time frames to conform. 1. Patient #7 had a start of care date of 4/3/2024. Clinical record revealed the following: a. The comprehensive assessment for start of care, dated as initiated on 4/3/24, was not electronically signed as completed until 4/10/24, which exceeded the requirement by 3 days. The agency failed to complete the start of care comprehensive assessment within 5 calendar days after the start of care. The above findings were reviewed with the agency Administrator.

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 agency staff interviews, record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 4 of 7 sampled patients (Patients #2, #5, #6 and #7). 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. 3. Patient #5 had a start of care date of 8/12/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 08/12/24, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. The RN failed to complete a drug regimen review that included the 5 required components of ineffective drug therapy, significant side effects, potential drug interactions, duplicate drug therapy and non-compliance with therapy. 4. Patient #7 had a start of care date of 4/3/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 04/3/24, included documentation of potential drug interactions and compliance, but lacked documentation of ineffective drug therapy, side effects and duplicate medications. b. Recertification comprehensive assessment, dated 5/29/24, included documentation of potential drug interactions, but lacked documentation of ineffective drug therapy, compliance with medication, duplicate medications and side effects. c. Resumption of Care comprehensive assessment, dated 7/9/24, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. No further information was provided by the agency prior to the end of the survey. According to the agency policy, titled Drug Regimen Review and dated October 2023, on admission the Registered Nurse (RN) shall check all medications a patient may be taking to identify potential adverse effects and drug interactions, including ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with therapy. The nurse shall review all medication effectiveness to ensure appropriateness, and to identify potential interactions, potential side effects, ineffective drug therapy or duplicate drug therapy. The drug regimen review (DRR) will be completed when a comprehensive assessment is completed: upon admission, every 60 days following admission, resumption of care, and discharge. During an interview on 8/27/24 at 1:11 PM, Staff B, Clinical Manager, reported RNs complete a drug regimen review at the time of start of care, resumption of care, recertification and at discharge. 1. Patient #2 had a start of care date of 11/28/23. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 11/28/23, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. b. Resumption of Care comprehensive assessment, dated 1/23/24, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. c. Recertification comprehensive assessments, dated 3/25/24, 5/22/24 and 7/24/24, included documentation of duplicate drug therapy, potential drug interactions and compliance but lacked documentation of ineffective drug therapy and side effects. The RN failed to complete a drug regimen review that included the 5 required components of ineffective drug therapy, significant side effects, potential drug interactions, duplicate drug therapy and non-compliance with therapy. 2. Patient #6 had a start of care date of 8/25/23 and a discharge date of 2/20/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 8/25/23, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. b. Recertification comprehensive assessment, dated 10/20/23, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. c. Recertification comprehensive assessments, dated 12/21/23, included documentation of duplicate drug therapy, potential drug interactions and compliance but lacked documentation of ineffective drug therapy and side effects. d. Discharge comprehensive assessment, dated 2/20/24, included documentation of duplicate drug therapy and potential drug interactions but lacked documentation of ineffective drug therapy, side effects and compliance. The RN failed to complete a drug regimen review that included the 5 required components of ineffective drug therapy, significant side effects, potential drug interactions, duplicate drug therapy and non-compliance with therapy.

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 between day 56 and 60 of each 60 day certification period for 1 of 7 sampled patients requiring a recertification assessment. (Patient #1) 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. According to the policy, titled Clinical Records, dated February 2023, assessments must be completed and confirmed with an electronic signature within the specific regulatory time frames to conform. Patient #1 had a start of care date of 4/9/14. Clinical record review revealed: a. An update to the comprehensive assessment for recertification, dated as initiated on 4/12/24, was not electronically signed as completed until 4/20/24, 5 days into the new certification period. The assessment was not completed by day 60 as required by regulation. b. An update to the comprehensive assessment for recertification, dated as initiated on 6/12/24, was not electronically signed as completed until 6/17/24, 2 days into the new certification period. The assessment was not completed by day 60 as required by regulation. c. An update to the comprehensive assessment for recertification, dated as initiated on 8/9/24, was not electronically signed as completed until 8/17/24, 4 days into the new certification period. The assessment was not completed by day 60 as required by regulation. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. The above information was shared with the Agency Administrator and the Nursing Manager, prior to the end of the survey.

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 agency staff interview, clinical record review and agency policy review, the agency failed to ensure clinical documents were completed within regulation time frames or per agency policy for 1 of 7 sampled patients (Patient #4). Failure to maintain timely, accurate and appropriately authenticated and completed clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: According to the agency's policy, titled Clinical Records, dated November 2023, required documentation for each service provided must be completed within the following timeframes: home health aide and contracted service notes – 14 days, nursing notes – 5 days, other assessments per specific timeframe according to assessment type. During an interview on 8/27/24 at 1:11 PM, Staff A, Administrator, after reviewing the policy, reported nursing staff had 5 days to complete documentation unless specific assessment called for a specific time frame, home health aides and contracted therapy staff had 14 days to complete documentation. Patient #4 had a start of care date of 7/30/24. Clinical record review revealed: a. Skilled nurse visit note, dated 8/2/24 and 8/7/24, was completed on 8/20/24, 18 days after the visit and 13 days late per policy. b. Skilled nurse visit note, dated 8/7/24, was completed on 8/20/24, 13 days after the visit and 8 days late per policy. The skilled nurse failed to complete visit documentation per agency policy. The above information was reviewed with the Administrator.

The recertification survey, dated 10/4/2021 through 10/6/2021, identified the home health agency was found to be in substantial compliance in relation to emergency preparedness regulations.

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 10/4/2021 through 10/6/2021. The agency was found to be in substantial compliance in relation to 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 the following standard level home health regulations:

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, agency clinicians failed to complete an update to the comprehensive assessment at recertification, between days 56 to 60 in the certification period, for 3 of 3 sampled patients requiring a recertification assessment (Patients #2, #4 and #5). The agency reported a census of 35 patients at the time of the survey. Failure to complete the updates to the comprehensive assessment between days 56 to 60 increased the potential that patients might not receive services in a timely manner according to assessed needs. Findings include: Review of the agency's policy, titled Client Reassessment Update of the Comprehensive Assessment, dated 8/2021, identified clinicians must complete the update to the comprehensive assessment at recertification during the last five days of every 60 day period, day 56 to 60, beginning with the start of care date. 1. Patient #4 had a start of care date of 7/9/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for 1 to 2 nursing visits every other month to assess the patient and provide supervision of the home health aide and orders for homemaker services with personal cares 2 visits per week. b. The update to the comprehensive assessment completed at the time of recertification, dated 8/31/21, included a signature of completion, dated 9/6/21. The nurse completed the assessment visit on 8/31/21, 2 days early (day 55). 2. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: a. The POCs, dated 4/6/21 to 6/4/21, 6/5/21 to 8/3/21 and 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. b. The update to the comprehensive assessment completed at the time of recertification, dated 4/1/21, included a signature of completion, dated 4/7/21 (completed 2 days late). c. The update to the comprehensive assessment completed at the time of recertification, dated 6/1/21, included a signature of completion, dated 6/15/21 (completed 16 days late). d. The update to the comprehensive assessment completed at the time of recertification, dated 8/3/21, included a signature of completion, dated 8/10/21 (completed 7 days late). On 10/5/21 at 1:30 PM, during an interview, the Clinical Manager reported there was no audit trail in the computer system and the nurse completing the assessments completed them late. 3. Patient #2 had a start of care date of 4/3/19. Clinical record review revealed the following: a. The Plans of Care, dated 3/23/21 to 5/21/21 and 5/22/21 to 7/20/21, included physician orders for skilled nursing services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 5/19/21 (day 58 of the certification period) but was not completed until 6/21/21, 31 days into the new certification period. The certification period ended on 5/21/21. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure accurate completion of all pertinent components of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient hospital admission for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #5). The agency provided services to 35 patients at the time of the survey and performed 6 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 timely manner to meet individualized patient needs. Findings include: Review of the agency's policy, titled Client Reassessment Update of the Comprehensive Assessment, dated 8/2021, identified clinicians must complete the update to the comprehensive assessment at resumption of care within 48 hours of the patient's return home or of the organization's knowledge of the patient's return from a 24-hour hospital admission for other than diagnostic testing. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: a. The POC, dated 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. b. An update to the comprehensive assessment completed at the time of resumption of care (ROC), dated 9/1/21, identified the patient discharged from the hospital on 8/31/21 and included a signature of completion of the assessment, dated 9/13/21 (completed 11 days late). c. An update to the comprehensive assessment completed at the time of ROC, dated 9/28/21, identified the patient discharged from the hospital on 9/27/21 and included a signature of completion of the assessment, dated 10/4/21 (completed 5 days late). The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency clinicians fully completed an update to the comprehensive assessment at the time of discharge for 1 of 1 sampled patients requiring a discharge comprehensive assessment (Patient #7). The agency reported a census of 35 patients at the time of the survey and discharged 25 patients in the previous 6 months. Failure to accurately and thoroughly complete discharge comprehensive assessments increased the potential that patients discharge planning and future services provides by other resources would fail to identify and meet the individualized needs of the patient. Findings include: Review of the agency's policy, titled Client Discharge, dated 8/2021, identified when a agency staff discharge a patient from home health services, agency staff shall complete all documentation including the discharge Outcome and Assessment Information Set (OASIS) within 7 working days. Review of the agency's policy, titled Comprehensive Client Assessment, dated 8/2021, identified the assessment will be comprehensive, consistent with the patient's immediate needs and include the patient's identified need for home care, rehabilitative care, social, and discharge planning. Review of the agency's policy, titled Client Reassessment Update of the Comprehensive Assessment, dated 8/2021, identified clinicians will include the OMAHA system (series of questions related to medication regimen, health, psychosocial, emotional/mental health, cognition and level of function), OASIS data elements and vital signs. Patient #7 had a start of care date of 10/5/2020, received home health services billed to Medicare, required the completion and transmission of OASIS data elements and discharged from agency services on 10/14/2020. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/5/2020 to 12/3/2020, included orders for skilled nursing, home health aide, physical and occupational therapy services. b. A discharge summary, dated 10/15/2020, identified the patient chose to discharge from home health agency services to be admitted to the same agency's hospice services. The summary included documentation the patient discharged from home health on 10/14/2020 and the patient's last visit from the home health agency was on 10/12/2020. c. A discharge OASIS assessment, dated 10/15/2020, included documentation of the answer to OASIS questions, but lacked documentation of any vital signs or the completion of a drug regimen review. On 10/5/2021 at 9:32 AM, during an interview, the Clinical Manager reported the nurse did not complete an assessment visit, full update to the comprehensive assessment or drug regimen review, because the nurse completed a comprehensive assessment for the admission to hospice on 10/15/2020. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed a transfer summary and sent the transfer summary to the receiving facility for 1 of 2 sampled patients (Patient #5) reviewed requiring the completion of a transfer summary. The agency reported a census of 35 patients at the time of the survey. Failure to complete and send a transfer summary to the receiving facility placed agency patients at risk for not ensuring the safe and effective transition of patient care. Findings include: Review of the agency's policy, titled Client Transfer, dated 1/2018, identified the registered nurse (RN) must complete and send the transfer summary to the receiving facility or provider within 2 business days of a planned transfer or within 2 business of days of becoming aware of an unplanned transfer. The transfer summary will include documentation of services provided, reason for transfer, physical, psychosocial status, current medications, instructions and referrals provided to the patient and any existing advanced directives. Agency staff will maintain a copy of the transfer summary in the patient's chart. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: The POC, dated 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. a. The clinical record included documentation of home health aide visit notes, dated 8/28, 8/29, 8/30 and 8/31/21, which identified the home health aide did not provide services due to the patient being in the hospital. 1) An update to the comprehensive assessment completed at the time of resumption of care (ROC), dated 9/1/21, identified the patient discharged from the hospital on 8/31/21. 2) The clinical record lacked documentation of a transfer summary, contact with the patient's physician and lacked documentation an agency clinician or other staff contacted the hospital to provide information on the patient. b. The clinical record included documentation of home health aide visit notes, dated 9/19, 9/20, 9/21, 9/22 and 9/23/21, which identified the home health aide did not provide services due to the patient being in the hospital. 1) An update to the comprehensive assessment completed at the time of ROC, dated 9/28/21, identified the patient discharged from the hospital on 9/27/21. 2) The clinical record lacked documentation of a transfer summary, contact with the patient's physician and lacked documentation an agency clinician or other staff contacted the hospital to provide information on the patient. On 10/5/21 at 1:02 PM, during an interview, Staff C, Registered Nurse (RN), explained she did call the patient's physician both times to notify the physician of the patient's hospitalization, but she did not document this and she did not complete or send a transfer summary. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff notified the physician of the need to vary from the physician ordered Plan for Care for 2 of 7 sampled patients (Patients #5 and #6). The agency reported a census of 35 patients at the time of the survey. Failure to notify the patient's physician of the inability to follow the Plan of Care established by the physician placed patients at risk for not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: Review of the agency's policy, titled Plan of Care, dated 8/2021, identified agency staff will provide each patient with an individualized, physician authorized written Plan of Care (POC). Agency staff will provide care and services according the POC, will update the POC as frequently as the patient condition requires, but no less than every 60 days beginning with the start of care date and will notify the physician of any changes to the POC due to changes in the patient's health status. If agency staff do not implement a physician order or complete visits according to the ordered service frequency, agency staff will notify the physician. For missed skilled nursing visits, staff will send an interim physician order to report the change in frequency. For missed home health aide visits, staff will notify the physician in the 60 day summary and document the missed visits on the next POC. 1. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: The POC, dated 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. a. The clinical record included documentation of home health aide visit notes, dated 8/28, 8/29, 8/30 and 8/31/21, which identified the home health aide did not provide services due to the patient being in the hospital. 1) An update to the comprehensive assessment completed at the time of resumption of care (ROC), dated 9/1/21, identified the patient discharged from the hospital on 8/31/21. 2) The clinical record lacked documentation of contact with the patient's physician to notify the physician of the patient's hospitalization and need to hold services. b. The clinical record included documentation of home health aide visit notes, dated 9/19, 9/20, 9/21, 9/22 and 9/23/21, which identified the home health aide did not provide services due to the patient being in the hospital. 1) An update to the comprehensive assessment completed at the time of ROC, dated 9/28/21, identified the patient discharged from the hospital on 9/27/21. 2) The clinical record lacked documentation of contact with the patient's physician to notify the physician of the patient's hospitalization and need to hold services. On 10/5/21 at 10:59 AM, during an interview, the Clinical Manager reported agency clinicians did not get an order from the physician to hold services when the patient goes into the hospital. They notify the physician of the missed visits when the patient returns to services. On 10/5/21 at 1:02 PM, during an interview, Staff C, Registered Nurse (RN), explained she did call the patient's physician both times to notify the physician of the patient's hospitalization, but she did not document this. 3. Patient #6 had a start of care date of 7/27/21 and a discharge date of 1/25/21. Clinical record review revealed the following: a. The Plan of Care, dated 1/8/21 to 3/8/21, included orders for home health aide services 3 times per week. b. The week of 1/10/21 included documentation of 3 canceled/refused home health aide visits, dated 1/11/21, 1/13/21 and 1/15/21. The clinical record lacked documentation the physician was notified of the missed aide visits. On 10/5/21 at 1:30 PM, during an interview, the Clinical Manager reported the missed aide visits should have been entered in an interim physician order. She reviewed the paper chart and confirmed no interim physician order was generated for the missed aide services. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency clinicians accurately completed all required components comprising the Plan of Care for 4 of 7 sampled patients (Patients #1, #4, #5 and #7). The agency reported a current census of 35 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: Review of the agency's policy, titled Plan of Care, dated 8/2021, identified agency staff will provide each patient with an individualized, physician authorized written Plan of Care (POC). The POC will include the discipline, frequency and duration of visits, specific treatments and patient specific interventions. Agency staff will provide care and services according the POC and will update the POC as frequently as the patient condition requires, but no less than every 60 days beginning with the start of care date. 1. Patient #1 had a start of care date of 8/6/21. Review of the clinical record revealed the following: a. The POC, dated 8/6/21 to 10/4/21, included physician orders for skilled nursing visits 1 to 2 times per week every other week and homemaker services with personal cares 1 time per week. The POC included orders for the skilled nurse to supervise the home health aide every 14 days. b. Review of the clinical record on 10/4/21 revealed the lack of signed written assignment by a registered nurse (RN), but did include computerized task sheets that the home health aides used to document daily visits on with instructions for the home health aide to provide safety while the patient was in the shower, apply lotion to the legs, assist with dressing and shaving per the patient's request. On 10/4/21 at 2:45 PM, during an interview, the Clinical Manager reported they had program where they billed personal care under homemaker. The patient's are private pay with grant funding for the service and it is cheaper for the agency to put it on the POC as homemaker with personal cares rather than home health aide services. On 10/4/21 at 2:59 PM, during an interview, the Clinical Manager provided a written home health aide assignment, dated 8/6/21. She reported staff maintained the home health aide assignments for patients with homemaker with personal cares in a separate file until the patient discharged from services. Review of the written home health aide assignment, dated 8/6/21, revealed the assignment did not have a RN signature. The written instructions directed the home health aide to apply lotion to the patient's legs, assist with dressing and shaving the patient per the patient's request and provide safety while the patient was in the shower. The POC incorrectly identified the patient's home health aide services as homemaker with personal cares, failed to include a scope and frequency for home health aide services and failed to include physician orders for the home health aide to complete the task of shaving, a task above and beyond basic home health aide skills. 2. Patient #4 had a start of care date of 7/9/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for 1 to 2 nursing visits every other month to assess the patient and provide supervision of the home health aide and orders for homemaker services with personal cares 2 visits per week. b. The clinical record included documentation of a homemaker assignment with personal cares, dated 7/9/21, and included an RN signature, dated 7/9/21, with directions for the homemaker to assist the patient with a sponge bath, nail care with a cut and file per patient request, skin care with lotion to the arms, legs and back per patient request, shampoo hair per patient request, assist with dressing and undressing, back rub, perineal care/incontinence cares per patient request, transfers to wheelchair, bed and chair, ambulate per patient request or use wheelchair. The POC incorrectly identified the patient's home health aide services as homemaker with personal cares and failed to include a scope and frequency for home health aide services. 3. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: a. The POCs, dated 6/5/21 to 8/3/21 and 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. b. The POCs included orders for the skilled nurse to change the patient's suprapubic catheter size 24 French every month and as needed, but failed to include a bulb (balloon-like device inserted into the bladder to hold the catheter in place) inflation size/amount. c. The POC, dated 6/5/21 to 8/3/21, did not include any physician orders for the home health aide to complete tasks for the patient requiring extra competency skills above and beyond basic home health aide skills. The home health aide task sheets, dated 8/1, 8/2 and 8/3/21, included the extra skills tasks of transferring the patient with a Hoyer lift (type of mechanical lift), applying ointment (medicated) to the patient's stump (remainder of the limb after surgical removal of a partial limb), colostomy care as needed and catheter care. d. The POC, dated 8/4/21 to 10/2/21, included physician orders for the home health aide to complete the extra skills tasks of catheter care and Hoyer lift transfer. The home health aide task sheets, dated 8/4 through 9/23/21, included the additional extra skills tasks of applying ointment (medicated) to the patient's stump and colostomy care as needed. The clinical record lacked documentation of a written home health aide assignment completed by a RN. On 10/5/21, the Clinical Manager provided a a copy of a written home health aide assignment, signed by Staff C, RN, on 4/22/18. The assignment directed the home health aide to complete a partial bed bath, catheter care, ostomy care, lotion to arms and legs for skin care, nail care, bed shampoo, assist with dressing/undressing, perineal care and transfer the patient with a Hoyer lift. On 10/5/21 at 1:26 PM, during an interview, Staff C, RN, reported the ointment the home health aides applied to the patient's stump was Bactroban. Review of the POCs revealed an order for Bactroban ointment 2 percent to the left flank site daily until healed, but lacked a physician order to apply Bactroban ointment to the patient's stump. 4. Patient #7 had a start of care date of 10/5/2020 and discharged from agency services on 10/14/2020. Review of the clinical record revealed the following: a. The POC, dated 10/5/2020 to 12/3/2020, identified the patient had an indwelling Foley urinary catheter and included a physician order for the skilled nurse to assess the catheter as needed. The POC failed to identify a size or bulb inflation size/amount for the catheter. b. The initial comprehensive assessment, dated 10/5/2020, identified the patient had a closed blister on the left buttock and the family of the patient was applying Desitin to the wound. The POC failed to identify the left buttock wound and include orders for the application of Desitin to treat the wound. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to update the Plan of Care with interim physician orders for 4 of 4 sampled patients (Patients #1, #5, #6 and #7) with interim orders. The agency reported a current census of 35 patients at the time of the survey. Failure to update the Plan of Care with all interim physician orders received during the certification period increased the potential for medication errors in administration or inaccurate provision of care. Findings include: Review of the agency's policy, titled Plan of Care, dated 8/2021, identified agency staff will provide each patient with an individualized, physician authorized written Plan of Care (POC). Agency staff will provide care and services according the POC and will update the POC as frequently as the patient condition requires, but no less than every 60 days beginning with the start of care date. The POC must be current. 1. Patient #1 had a start of care date of 8/6/21. Review of the clinical record revealed the following: a. The POC, dated 8/6/21 to 10/4/21, included physician orders for skilled nursing visits 1 to 2 times per week every other week and homemaker services with personal cares 1 time per week. b. Interim physician orders, dated 8/27/21 and an effective date of 8/19/21, included the following: skilled nurse visit on 8/23/21 to obtain a basic metabolic panel (blood draw); start potassium chloride 10 milliequivalents tablets twice per day; change Glimepiride 1 milligram tablet every day to 2 mg every day; change Insulin Aspart 100 Unit per milliliter (ml) pen 5 units subcutaneous injection before meals three times per day to 7 units before meals three times per day; change Levemir Flexpen Insulin 100 units/ml 15 units every day subcutaneous injection to 20 units every day. The clinical record lacked documentation of an updated POC which contained the interim physician orders. On 10/4/21 at 2:50 PM, during an interview, the Clinical Manager reported agency staff had not been doing updated POCs. Upon reviewing the electronic clinical record and discovering the system was capable of creating a POC update, the Clinical Manager reported she had been unaware the computer software had been capable of this. She created a POC update for this patient, and while the medication orders transferred over to the POC update, she agreed the order for the extra skilled nurse visit and blood draw did not. 2. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: a. The POC, dated 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. b. An interim physician order, dated 9/10/21, included an effective date of 8/26/21 for 6 as needed skilled nursing visits 8/26 through 9/30/21 for catheter issues, skin, bowel, respiratory complications and lab work. c. An interim physician order, dated 9/7/21, included an effective date of 9/1/21 for resumption of services after a hospital stay, international normalized ratio (INR- type of blood test related to blood clotting ability) on 9/3/21 per monitor due to antibiotic therapy and Cefdinir capsule 300 mg twice per day starting 9/1/21 and ending 9/14/21. d. An interim physician order, dated 9/14/21, included an effective date of 9/14/21 to hold Warfarin dose until 9/17/21 after rechecking INR and reporting to the patient's physician. The order also included a change in the Warfarin from 5 mg daily by mouth to 5 mg daily alternating with 4.5 mg every third day. e. A skilled nursing visit note, dated 9/17/21, included documentation the nurse obtained a complete blood count (CBC) and complete metabolic panel (CMP) blood draw per physician orders. The clinical record lacked documentation of a written order for the nurse to obtain the CBC and CMP. f. An interim physician order, dated 10/4/21, included an effective date of 9/28/21 to resume services after a hospital stay with a plan for the patient to return to the hospital due to a planned hip surgery due to infection, start Cipro 750 mg orally twice per day, change Warfarin 5 mg daily alternating with 4.5 mg every third day to 4.5 mg daily. The clinical record lacked documentation of an updated POC which contained the interim physician orders. On 10/5/21 at 1:02 PM, during an interview with Staff C, Registered Nurse (RN), she reported she had received verbal orders from the physician to complete the blood draw tests, but forgot to write the order. 3. Patient #7 had a start of care date of 10/5/2020 and discharged from agency services on 10/14/2020. Review of the clinical record revealed the following: a. The POC, dated 10/5/2020 to 12/3/2020, included physician orders for skilled nursing, home health aide, physical therapy and occupational therapy services. b. An interim physician order, dated 10/14/2020, included an effective date of 10/8/2020 for Lactulose syrup 10 grams per 15 ml for constipation as needed daily. The clinical record lacked documentation of an updated POC which contained the interim physician order. On 10/5/21 at 9:32 AM, during an interview, the Clinical Manager confirmed the clinical record lacked documentation of an updated POC with the interim physician order. 4. Patient #6 had a start of care date of 1/8/21 and a discharged date of 1/25/21. Clinical record review revealed the following: a. The Plan of Care, dated 1/8/21 to 3/8/21, included physician orders for skilled nursing services and occupational therapy services. b. Interim physician order, dated 1/14/21, for occupational therapy frequency and treatment. c. Interim physician orders, dated 1/15/21 and 1/18/21, for lab draw and medication change. The clinical record lacked documentation of updated Plans of Care with the 1/14/21, 1/15/21 and 1/18/21, interim physician orders. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to report changes in patient clinical findings to the physician for 1 of 2 sampled patients (Patient #7) with wounds. The agency reported a census of 35 patients at the time of the survey. Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: Review of the agency's policy, titled Plan of Care, dated 8/2021, identified agency staff will provide each patient with an individualized, physician authorized written Plan of Care (POC). Agency staff will provide care and services according the POC, will update the POC as frequently as the patient condition requires, but no less than every 60 days beginning with the start of care date and will promptly notify the physician of any changes that suggest a need to alter the POC including any change in the patient's health status. Patient #7 had a start of care date of 10/5/2020 and discharged from agency services on 10/14/2020. Review of the clinical record revealed the following: a. The POC, dated 10/5/2020 to 12/3/2020, included physician orders for skilled nursing, home health aide, physical therapy and occupational therapy services. The POC included orders for the nurse to assess the patient's skin integrity and to provide a treatment for "open wound care/dressing". The POC did not specify any type of wound care treatment orders or identify any specific wound. b. The initial comprehensive assessment, dated 10/5/2020, identified the patient had a closed blister on the left buttock measuring 2.5 centimeters (cm) in length and 2.3 cm in width. The nurse documented the family of the patient was applying Desitin to the wound. c. The skilled nursing visit, dated 10/12/2020, included documentation the nurse assessed the patient had an open wound on the left and right buttocks, both measuring 6.0 cm in length, 3.0 cm in width and 0.1 cm in depth. The clinical record lacked the nurse contacted the physician to notify the physician of the patient's wounds and determine if the physician wanted to order any type of treatment. d. The clinical record included a copy of a discharge summary, dated 10/15/2020, which identified the patient discharged from home health services on 10/14/2020 to go to the agency's hospice services. The nurse documented in the discharge summary that the patient had developed 2 pressure ulcers bilaterally on the buttocks. The clinical record and discharge lacked documentation the nurse sent the discharge summary to the patient's physician. On 10/5/21 at 9:10 AM, during an interview, the surveyor notified the Clinical Manager of the inability to find evidence of physician notification of the worsening of the patient's left buttock wound and the development of the wound on the right buttocks. The Clinical Manager confirmed an inability to find evidence of documentation of physician notification and evidence the physician received a copy of the discharge summary. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: 3. Patient #3 had a start of care date of 9/29/21. On 10/5/21 at 1:00 PM, the surveyor accompanied Staff D, Physical Therapy Assistant on a home observation visit. During the home visit, the surveyor requested review of the agency's folder kept by the patient. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the name and contact information of the clinical manager. The surveyor observed no documentation including the name and contact information of the clinical manager posted in the patient's home. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. Based on agency staff interview, home visit observation, admission packet review and agency policy review, the agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address) for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation. The agency reported a census of 35 patients at the time of the survey. Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: Review of the agency's policy, titled Plan of Care, dated 8/2021, revealed agency staff will provide agency patients with the name and contact information of the Clinical Manager. Review of the agency's admission packet revealed a lack of identification of the agency's clinical manager and contact information for the clinical manager. On 10/4/21 at 10:50 AM, during an interview, the Administrator reported there was a cell phone number for the Clinical Manager on the front of the packet, but it did not identify the Clinical Manager's name. She reported the current Clinical Manager took over on 6/5/2020, and agency staff had not updated the packets since then. 1. Patient #1 had a start of care date of 8/6/21. Review of the clinical revealed the following: The Plan of Care, dated 8/6/21 to 10/4/21, included orders for skilled nursing services. On 10/4/21 at 3:20 PM, during a home visit observation with Staff C, RN, review of the patient's admission packet revealed a lack of name and contact information for the Clinical Manager. Staff C, RN, confirmed the information was missing and wrote this information on the patient's packet. 2. Patient #2 had a start of care date of 4/3/19. On 10/5/21 at 9:55 AM, during a home observation visit with Staff E, Registered Nurse, the surveyor observed the admission packet in the home. The packet lacked documentation of the Clinical Manager's name.

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: On 10/4/21 at 2:12 PM, during an interview, the Clinical Manager reported the RN case manager was responsible for creating the home health aide assignment, reviewing it every 60 days and updating the assignment with changes. 1. Patient #1 had a start of care date of 8/6/21. Review of the clinical record revealed the following: a. The POC, dated 8/6/21 to 10/4/21, included physician orders for skilled nursing visits 1 to 2 times per week every other week and homemaker services with personal cares 1 time per week. The POC included orders for the skilled nurse to supervise the home health aide every 14 days. b. Review of the clinical record on 10/4/21 revealed the lack of signed written assignment by a registered nurse (RN), but did include computerized task sheets that the home health aides used to document daily visits on with instructions for the home health aide to provide safety while the patient was in the shower, apply lotion to the legs, assist with dressing and shaving per the patient's request. On 10/4/21 at 2:59 PM, during an interview, the Clinical Manager provided a written home health aide assignment, dated 8/6/21. She reported staff maintained the home health aide assignments for patients with homemaker with personal cares in a separate file until the patient discharged from services. Review of the written home health aide assignment, dated 8/6/21, revealed the assignment did not have a RN signature. The written instructions directed the home health aide to apply lotion to the patient's legs, assist with dressing and shaving the patient per the patient's request and provide safety while the patient was in the shower. 2. Patient #4 had a start of care date of 7/9/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for 1 to 2 nursing visits every other month to assess the patient and provide supervision of the home health aide and orders for homemaker services with personal cares 2 visits per week. b. The clinical record included documentation of a homemaker assignment with personal cares, dated 7/9/21, and included an RN signature, dated 7/9/21, with directions for the homemaker to assist the patient with a sponge bath, nail care with a cut and file per patient request, skin care with lotion to the arms, legs and back per patient request, shampoo hair per patient request, assist with dressing and undressing, back rub, perineal care/incontinence cares per patient request, transfers to wheelchair, bed and chair, ambulate per patient request or use wheelchair. The clinical record lacked documentation of a home health aide assignment. 3. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: a. The POCs, dated 6/5/21 to 8/3/21 and 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. b. The home health aide task sheets with home health aide visit note documentation, dated 8/1 through 9/23/21, included the tasks of transferring the patient with a Hoyer lift (type of mechanical lift), applying ointment (medicated) to the patient's stump (remainder of the limb after surgical removal of a partial limb), colostomy care as needed, bed shampoo as needed, nail care as needed and catheter care. The tasks sheets include documentation the patient refused assistance with colostomy care every time. On 10/5/21 at 1:26 PM, during an interview, Staff C, RN, reported the ointment the home health aides applied to the patient's stump was Bactroban. Staff C, RN, explained her awareness of the patient never having accepted help with colostomy care. The task sheet included instructions for as needed tasks, but failed to include specific instructions for how the home health would know when the home health aide needed to complete the as needed tasks. The RN assigned a task of applying medicated ointment to the patient's stump without an order from the physician to use Bactroban for this purpose. The RN was aware the home health aides had never completed colostomy care and failed to remove this task from the home health aide assignment. c. The clinical record lacked documentation of a written home health aide assignment completed by a RN or a signed computerized version of the home health aide assignment. On 10/5/21, the Clinical Manager provided a a copy of a written home health aide assignment, signed by Staff C, RN, on 4/22/18. The assignment was kept in a separate file, not the patient's medical record. The assignment directed the home health aide to complete a partial bed bath, catheter care, ostomy care, lotion to arms and legs for skin care, nail care, bed shampoo, assist with dressing/undressing, perineal care and transfer the patient with a Hoyer lift. The written assignment provided by the Clinical Manager did not match the computerized home health aide task sheets the home health aides completed for visit documentation. 4. Patient #7 had a start of care date of 10/5/2020 and discharged from agency services on 10/14/2020. Review of the clinical record revealed the following: a. The POC, dated 10/5/2020 to 12/3/2020, included physician orders for skilled nursing and home health aide services. b. The initial comprehensive assessment, dated 10/5/2020, included documentation the patient had a closed blister wound on the left buttock and the family was applying Desitin to the wound. c. A written home health aide care plan, dated and signed by the RN on 10/5/2020, included instructions to the home health aide to complete the tasks of sponge bath and "skin care". The assignment failed to specify what the home health aide needed to do in order to provide skin care. On 10/5/21 at 1:30 PM, during an interview, the Administrator reported the forms to for the nurses to fill out for the home health aide assignment had been modified so the nurse would have to be more specific in describing what the home health aide needed to do in order to complete assigned tasks. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. Based on clinical record review, agency policy review and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 4 of 5 sampled patients receiving home health aide services (Patients #1, #4, #5 and #7). The agency reported a census of 35 patients, including 29 who received home health aide services. 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 the Policy and Procedure titled Supervision & Protocols related to Ancillary Personnel, Dated August 2021, The HCA (home care aide) supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to following the client's plan of care for completion of tasks assigned to the HCA by the RN.

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 #4 and #7). The agency reported a current census of 35 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 Supervision & Protocols related to Ancillary Personnel, dated August 2021, identified specific directions for cares to be given will be provided by the registered nurse to the home care aide prior to her first visit. The nurse will document the home care aide orientation in the visit note or communication log.On 10/4/21 at 2:12 PM, during an interview, the Clinical Manager reported if the home health aide is unable to complete an assigned task, the home health aide will document the reason for why. If the patient requests the home health aide complete an unassigned task, the home health will contact the RN for approval prior to completing the task. 1. Patient #4 had a start of care date of 7/9/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for 1 to 2 nursing visits every other month to assess the patient and provide supervision of the home health aide and orders for homemaker services with personal cares 2 visits per week. b. The clinical record included documentation of a homemaker assignment with personal cares, dated 7/9/21, and included an RN signature, dated 7/9/21, with directions for the homemaker to assist the patient with a sponge bath, nail care with a cut and file per patient request, skin care with lotion to the arms, legs and back per patient request, shampoo hair per patient request, assist with dressing and undressing, back rub, perineal care/incontinence cares per patient request, transfers to wheelchair, bed and chair, ambulate per patient request or use wheelchair. c. The home health aide visit notes, dated 8/3, 8/6, 8/10, 8/13, 8/17, 8/20, 8/24, 8/27, 8/31, 9/3, 9/7, 9/10, 9/14, 9/17, 9/24, 9/28 and 10/1/21, lacked documentation the home health aide completed the assigned tasks of ambulation, back rub, or nail care and lacked a reason why the home health aide did not complete the tasks. d. The home health aide visit notes, dated 8/27 and 9/3/21, included documentation the home health aide completed the unassigned task of oral care. e. The home health aide visit note, dated 9/21/21, lacked documentation and a reason why the home health aide failed to complete the assigned tasks of transferring the patient, nail care and shampooing the patient's hair. 2. Patient #7 had a start of care date of 10/5/2020 and discharged from agency services on 10/14/2020. Review of the clinical record revealed the following: a. The POC, dated 10/5/2020 to 12/3/2020, included physician orders for skilled nursing and home health aide services. b. A written home health aide care plan, dated and signed by the RN on 10/5/2020, included instructions to the home health aide to complete the tasks of sponge bath, skin care, shampoo, catheter care, ambulate with a walker, assist with dressing/undressing and assist with transfers. c. The home health aide visit note, dated 10/7/2020, included documentation the home health aide completed the unassigned task of oral care without any documentation of RN approval to do the task. The home health aide failed to document the completion of the task for catheter care or a reason why the home health aide did not complete the task. d. The home health aide visit note, dated 10/9/2020, lacked documentation and a reason why the home health aide did not complete the assigned task of transferring the patient. e. The home health aide visit note, dated 10/14/2020, lacked documentation and a reason why the home health aide did not complete the assigned task of assisting the patient with undressing/dressing. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included timely documentation of interventions and maintained pertinent current information in the patient record for 4 of 7 sampled patients (Patients #1, #4, #5 and #6). The agency reported a current census of 35 patients at the time of the survey. Failure to ensure the patient's clinical record included current documentation of interventions and other pertinent medical information placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's policy, titled Clinical Records, dated 8/2021, identified the clinical record will include pertinent past and current findings including documentation of patient assessment information and interventions made by disciplines providing services to the patient, physician orders and coordination of care and services. Home health aide documentation must be completed and filed in the record within 14 working days. Skilled nursing documentation must be completed and signed in the record within 5 working days. According to the agency policy, titled Client Transfer, dated May 2020, a transfer summary form will be completed by the skilled nurse and sent to the accepting agency within 2 business days of a planned transfer, if the client's care will be immediately continued in a health care facility; or sent within 2 business days of becoming aware of an unplanned transfer, if the client is still receiving care in a health care facility at the time when the agency becomes aware of the transfer. 1. Patient #1 had a start of care date of 8/6/21. Review of the clinical record on 10/4/21 revealed the following: a. The POC, dated 8/6/21 to 10/4/21, included physician orders for skilled nursing visits 1 to 2 times per week every other week and homemaker services with personal cares 1 time per week. b. The skilled nursing visit note, dated 8/19/21, included documentation of a signature of completion, dated 8/29/21 (completed 3 days late per agency policy). c. Interim physician orders, dated 8/27/21 and an effective date of 8/19/21, included the following: skilled nurse visit on 8/23/21 to obtain a basic metabolic panel (blood draw); start potassium chloride 10 milliequivalents tablets twice per day; change Glimepiride 1 milligram tablet every day to 2 mg every day; change Insulin Aspart 100 Unit per milliliter (ml) pen 5 units subcutaneous injection before meals three times per day to 7 units before meals three times per day; change Levemir Flexpen Insulin 100 units/ml 15 units every day subcutaneous injection to 20 units every day. The nurse failed to write the order within 5 business days of taking the order. d. A skilled nursing visit, dated 8/23/21, included documentation the nurse completed a laboratory blood draw for a basic metabolic panel (BMP). The clinical record lacked documentation of the laboratory results. On 10/4/21 at 3:33 PM, during an interview, the Clinical Manager provided a copy of the BMP lab draw results from 8/23/21. She reported it was in the filing system waiting to be filed in the patient's clinical record. e. The skilled nursing visit note, dated 9/1/21, included documentation of a signature of completion, dated 9/13/21 (completed 5 days late per agency policy). f. The patient's medical record last entry for home health aide visit documentation was dated 9/7/21. On 10/4/21 at 2:45 PM, during an interview, the surveyor notified the Clinical Manager of the inability to find any home health aide visit notes past 9/7/21. On 10/4/21 at 2:59 PM, during an interview, the Clinical Manager reported the home health aide visit notes were in a separate file waiting to be filed in the patient's chart. She provided home health aide visit notes, dated 9/14, 9/21, and 9/28/21. Agency staff failed to place the home health aide visit note, dated 9/14/21, in the patient's medical record timely according to agency policy. g. The skilled nursing visit note, dated 9/15/21, included documentation of a signature of completion, dated 10/1/21 (completed 9 days late per agency policy). 2. Patient #4 had a start of care date of 7/9/21. Review of the clinical record on 10/4/21 revealed the following: a. The Plan of Care (POC), dated 7/9/21 to 9/6/21, included physician orders for 1 to 2 nursing visits every other month to assess the patient and provide supervision of the home health aide and orders for homemaker services with personal cares 2 visits per week. b. Review of the clinical record on 10/4/21 revealed a lack of home health aide visit notes after 9/10/21. On 10/4/21 at 4:16 PM, during an interview, the surveyor notified the Clinical Manager of the inability to find home health aide visit notes in the clinical record after 9/10/21. The Clinical Manager thought the home health aide had completed more visits and agreed to look for the documentation. On 10/4/21 at 4:20 PM, during an interview, the Clinical Manager provided documentation of home health aide visit notes, dated 9/14, 9/17, 9/21, 9/24, 9/28 and 10/1/21. She reported they were waiting to be filed. Agency staff failed to place home health aide visit notes, dated 9/14 and 9/17/21, in the patient's medical record timely according to agency policy. 3. Patient #5 had a start of care date of 4/22/18. Review of the clinical record revealed the following: a. The POC, dated 8/4/21 to 10/2/21, included orders for skilled nursing 1 to 2 visits per week and home health aide services 7 days per week. b. A skilled nursing visit note, dated 8/24/21, included documentation of a signature of completion, dated 9/6/21 (completed 6 days late per agency policy). c. A skilled nursing visit note, dated 8/26/21, included documentation of a signature of completion, dated 9/6/21 (completed 4 days late per agency policy). d. An interim physician order, dated 9/10/21, included an effective date of 8/26/21 for 6 as needed skilled nursing visits 8/26 through 9/30/21 for catheter issues, skin, bowel, respiratory complications and lab work. The nurse failed to write the order within 5 business days of taking the order. e. A skilled nursing visit note, dated 9/7/21, included documentation of a signature of completion, dated 9/16/21 (completed 2 days late per agency policy). f. A skilled nursing visit note, dated 9/14/21, included documentation of a signature of completion, dated 9/23/21 (completed 2 days late per agency policy). g. A skilled nursing visit note, dated 9/17/21, included documentation the nurse obtained a complete blood count (CBC) and complete metabolic panel (CMP) blood draw per physician orders. The clinical record lacked documentation of a written order for the nurse to obtain the CBC and CMP. The nurse signed the visit note complete on 10/3/21 (9 days late). On 10/5/21 at 1:02 PM, during an interview with Staff C, Registered Nurse (RN), she reported she had received verbal orders from the physician to complete the blood draw tests, but forgot to write the order. The clinical record lacked documentation of the results of the completed laboratory blood draws done on 9/17/21. 4. Patient #6 had a start of care date of 1/8/21 and a discharge date of 1/25/21. Clinical record review revealed the Transfer oasis, dated 1/25/21, was marked completed on 3/16/21, 50 days after the assessment date, 48 days late per agency policy. On 10/5/21 at 11:18 AM, during an interview, the Clinical Manager reported the electronic medical record system did not have an audit trail identifying if the document had been locked and unlocked prior to the date listed on the document. The Clinical Manager reported the last date the document is locked is the date that shows on the printed document. The Administrator and Clinical Manager 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 send a transfer summary within 2 business days of a planned transfer or 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 home health agency becomes aware of the transfer for 1 of 1 sampled patients with transfer to a health care facility (Patient #6). The agency reported a current census of 35 patients at the time of the survey. 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 Client Transfer, dated May 2020, a transfer summary form will be completed by the skilled nurse and sent to the accepting agency within 2 business days of a planned transfer, if the client's care will be immediately continued in a health care facility; or sent within 2 business days of becoming aware of an unplanned transfer, if the client is still receiving care in a health care facility at the time when the agency becomes aware of the transfer. Patient #6 had a start of care date of 1/8/21 and a discharge date of 1/25/21. Clinical record review revealed the following: Discharge/transfer summary, dated 1/25/21, identified the patient discharged from home health services effective 1/25/21. The patient's clinical record lacked documentation the completed discharge/transfer summary had been sent to the physician. On 10/5/21 at 1:30 PM, the Clinical Manager reported she called the physician office and was told a copy of the discharge summary was in the patients clinic record. The Clinical Manager reported the agency process for tracking the discharge summaries had not been followed and she was unsure when the summary had been sent. The clinical record lacked documentation of when the completed discharge/transfer summary had been sent to the physician. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.