Every finding on record at Lkb Health Care, Ltd

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 08/16/24. Standard level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 08/14/24. The Emergency Preparedness plan included the last review date of 03/26/21. As of 08/14/24, the Emergency Preparedness Plan lacked an update, as required. 2. During an interview with the Administrator and Director of Nursing on 08/14/24 at 2:30 PM, the Administrator confirmed the Agency failed to review and update the Emergency Preparedness plan.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure that the Emergency Preparedness Plan was established based on a risk assessment using an all-hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 08/14/24. The Emergency Preparedness Plan included the last Hazard Vulnerability Assessment dated 2021. The Emergency Preparedness Plan lacked documentation that a facility-based and/or community-based risk assessment was completed for 2022 and 2023. 2. During an interview with the Administrator and Director of Nursing on 08/14/24 at 2:30 PM, the Administrator confirmed that the Agency lacked a risk assessment after 2021.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to ensure testing of the Emergency Preparedness Plan was conducted. Findings include: 1.The Agency’s Emergency Preparedness Plan was reviewed on 08/14/24 and lacked documentation of the testing of the Emergency Preparedness Plan. The last testing was conducted in 2021. 2. During an interview with the Administrator and Director of Nursing on 08/14/24 at 2:30 PM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 08/16/24. Standard level deficiencies cited. Abbreviations: BP = Blood Pressure POC =Plan of Care SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patients

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and Staff interview, it was determined in 258 of 505 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Finding include: 1. The Error Summary report for 08/08/23 -08/07/24, was reviewed on 08/13/24 at 11:30 AM. The report included error # -3330 for 258 of 505 submissions, 51.09 % of the reports submitted were more than 30 days after the M0090. 2. During an interview with the Administrator on 08/13/24 at 11:50 AM, the Administrator confirmed that the error occurred.

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 the clinical record review and Staff interview, it was determined in 5 of 7 (Pts. # 1, 4, 5, 2 and 3) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 4. Pt. #2 was admitted to Home Health Services on 08/03/23 with the diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 08/14/24. The POC effective 05/29/24, required Aide frequency 1 week 9. The clinical record contained Aide notes, indicating the Aide provided service 2 times a week (06/18/24, 06/20/24, 06/24/24, 06/26/24, 07/02/24, 07/04/24, 07/09/24, 07/11/24, 07/16/24 and 07/18/24). The Aide frequency was not followed, as ordered in the POC. 5. Pt. #3 was admitted to Home Health Services on 06/23/24 with the diagnosis: Other Specified Disorders of Muscle. The clinical record was reviewed on 08/15/24. The POC effective 06/23/24 required: “….Notify Physician of vital sign parameters out of range:….Diastolic BP:….Less Than (Findings include: 1. Pt. #1 was admitted to the Home Health Services on 01/10/24 with the diagnosis of: Encounter for Change or Removal of Surgical Wound Dressing. The clinical record was reviewed on 08/13/24. The clinical record contained a recertification POC dated 07/08/24, that required the SN to “perform wound care to the right below amputation”, 1 time a week for 9 weeks. The POC lacked the diagnosis of the amputation. 2. Pt. #4 was admitted to the Home Health Services on 03/12/24 with the diagnosis of: Essential Primary Hypertension. The clinical record was reviewed on 08/14/24. The clinical record contained a POC dated 07/10/24, that required the SN to assess the patient’s heart rate, 1 time a week for 9 weeks. The SN lacked the heart rate assessment on 07/31/24. 3. Pt. #5 was admitted to the Home Health Services on 02/14/24 with the diagnosis of: Essential Primary Hypertension. The clinical record was reviewed on 08/13/24. The clinical record contained a POC dated 06/13/24, that required the SN to notify the physician of the blood sugar greater than 200 or less than 70, 1 time a week for 9 weeks. The SN lacked the blood sugar assessment for the entire certification period.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 5 of 7 (Pts. #2, 3, 4, 6 and 7), the Agency failed to ensure Pts. were assessed for the Influenza and / or Pneumonia vaccination status, as required. Findings include: 1. The following clinical records were reviewed from 08/13/24 at 2:00 PM to 08/15/24 at 9:00 AM: Pt. #2 SOC 08/03/23 Lacked Pneumonia vaccination assessment. Pt. #3 SOC 06/23/24 Lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 03/12/24 Lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 02/20/24 Lacked Pneumonia vaccination assessment. Pt. #7 SOC 09/30/23 Lacked Influenza and Pneumonia vaccination assessment. The records lacked documentation that the Pts. were completely assessed for the need of Influenza and/or Pneumonia vaccine. 2. During interviews with the Director of Nursing on 08/15/24 at 9:45 AM to 2:00 PM, the Director of Nursing confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home visit observation, Agency policy and Staff interview, it was determined that in 1 of 3 (Pt. #2) home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as per Agency policy. Findings include: 1. Pt. #2 was admitted to Home Health Services on 08/03/23 with the diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. On 08/14/21 at 9:30 AM, Employee #14(RN) was observed during the homevisit, to put down nursing bag on Pt. #2's walker (rollator) without sanitizing the surface or placing a barrier. During an interview with Employee #14 on 08/14/24 at 10:00 AM, Employee #14 stated that the Pt.'s walker was clean and was not being used. Employee #14 confirmed that she did not sanitize nor put a barrier before setting down the nursing bag. 2. The Agency policy titled: "Nursing Bag" indicated: “….When in a client’s home, place a waterproof disposable barrier on a clean and dry surface then place the bag down on the barrier …." 3. During an interview with the Director of Nursing on 08/15/24 at 9:45 AM, the Director of Nursing stated that the Agency policy was not followed and confirmed the above findings.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 1 of 1 (Pt. #2) clinical records with Aide services, the Agency failed to ensure that the Aide performed duties as assigned. Findings include: 1. Pt. #2 was admitted to Home Health Services on 08/03/23 with the diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 08/14/24. The record contained Aide notes, indicating the Aide provided service 2 times a week (dated 06/18/24, 06/20/24, 06/24/24, 06/26/24, 07/02/24, 07/04/24, 07/09/24, 07/11/24, 07/16/24 and 07/18/24) and documented completed tasks including checking vital signs, bed bath, hair care, oral care, skin care, peri care, shave, assist with dressing, medication reminder, make bed, change linen, light housekeeping, incontinence care, record bowel movement, assist with transfer, assist with ambulation, range of motion, meal set up and assist with feeding. The record lacked Aide duties as established on a plan of care and assigned by the contracted RN. 2. During an interview with the Director of Nursing on 08/15/24 at 9:45 AM, the Director of Nursing confirmed the above findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 1 of 1 (Pt. #2) clinical records where in the Pt. received Aide services, the Agency failed to ensure the RN conducted Aide supervision every 14 days. Findings include: 1. Pt. #2 was admitted to Home Health Services on 08/03/23 with diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 08/14/24. The record contained Aide notes, indicating the Aide provided service 2 times a week (06/18/24, 06/20/24, 06/24/24, 06/26/24, 07/02/24, 07/04/24, 07/09/24, 07/11/24, 07/16/24, 07/18/24, 07/23/24). As of 08/15/24, the record lacked documentation of the Aide supervision by the RN. 2. During an interview with the Director of Nursing on 08/15/24 at 9:45 AM, the Director of Nursing confirmed the above findings.

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 clinical record review and Staff interview, it was determined that in 1 of 2 (Pt. #6) closed clinical records reviewed, the Agency failed to ensure the Physician or health care facility where patient was receiving care, was sent a copy of the Transfer summary and/or Discharge summary. Findings include: 1. Pt. #6 was admitted to Home Health Services on 02/20/24 with the diagnosis: Displaced Fracture of Head of Left Radius, Subsequent for Close Fracture with Routine Healing and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 08/14/24. The transfer discharge assessment and summary indicated Pt. #6 was transferred and discharged to the hospital dated 03/25/24. The record lacked documentation that the transfer / discharge summary was sent to the Physician and/or hospital where Pt. was receiving care. 2. During an interview with the Director of Nursing on 08/15/24 at 9:45 AM, the Director of Nursing confirmed the above findings.

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 the clinical record review and Staff interview, it was determined in 3 of 7 (Pts. #5, 3 and 6) clinical records reviewed, the clinical records were not completed as required. 2. Pt. #3 was admitted to Home Health Services on 06/23/24 with the diagnosis: Other Specified Disorders of Muscle. The clinical record was reviewed on 08/15/24. The record included forms titled: “Authorization and Agreements” and “Patient Advance Directive Statement”, and lacked information on Advance Directives, as the form required. 3. Pt. #6 was admitted to Home Health Services on 02/20/24 with the diagnosis: Displaced Fracture of Head of Left Radius, Subsequent for Close Fracture with Routine Healing and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 08/14/24. The SN note dated 02/26/24 lacked documentation of the Endocrine/Diabetes assessment. The same clinical record included a form titled: “Authorization and Agreements” and lacked information on Advance Directives, as the form required. The record also included the form: “Notice of Medicare Non-Coverage” signed by the Pt. and lacked information of when the services will end, as the form required. 4. During interviews with the Administrator and Director of Nursing on 08/14/24 at 2:00 PM and with the Director of Nursing on 08/15/24 at 9:45 AM, the Director of Nursing confirmed the above findings. Findings include: 1.Pt. #5 was admitted to the Home Health Services on 02/14/24 by the contracted RN, with the Diagnosis of: Essential (Primary) Hypertension. The clinical record was reviewed on 08/13/24. The clinical record was incomplete. The clinical record lacked the patient’s consent and the weekly visit notes after 07/21/24, at the time of the review. 2. Pt. #7 was admitted to the Home Health Services on 09/30/24 with the Diagnosis of: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 08/14/24. The clinical record was incomplete. The clinical record lacked the documentation date the discharge summary was sent to the physician, at the time of the review.

Recertification survey completed. Standard level deficiency cited. A Focused Infection Control Survey (FIC) was conducted on 07/23/2021. The facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviatios: Pt.= Patient Pts.= Patients #= Number AM= Morning SOC= Start of Care

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that clinical documents were complete. This was found in 7 of 7 (Pts.# 1,2 3,4,5,6 and 7 ) clinical records reviewed. Findings include: 1. The following clinical records were reviewed between 07/20/2021 and 07/22/2021. Pt. #1. SOC 05/12/2021. Pt. #2. SOC 05/12/2021. Pt. #3. SOC 04/19/2021. Pt. #4. SOC 11/25/2020. Pt. #5. SOC 10/14/2020. Pt. #6. SOC 05/29/2020. Pt. #7. SOC 11/20/2020. 2. The records contained an incomplete document titled, "Notice of Medicare Non-Coverage" signed by the patients. The documents were blank on the section that states... "The effective date coverage of your current Home Health services will end." 3. Findings of the incomplete documents were confirmed during interviews with the Administrator and Director of Nursing on 07/22/2021 between 10:00 AM and 11:30 AM.