Every finding on record at Loving Care Agency Inc

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 record review and interview, the home health agency failed to ensure the plan of care was updated to include all orders received from the primary care physician in 1 of 4 clinical records reviewed. (#3) The findings include: Review of the agency policy revised 3/10/2021, titled "Physician Orders" stated "... The Plan of Care/Treatment must be reviewed and revised as frequently as the patient's condition or needs require ... The plan of Care/Treatment is reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires ... It is reviewed more frequently based upon: ... Changes regarding diagnosis, treatment including procedures, medications and equipment ...." Clinical record review on 3/9/2021 for patient #3, diagnosis: Lennox-Gastaut syndrome (severe form of epilepsy), start of care 11/25/2020, for certification period 1/24/2021 to 3/24/2021, evidenced an agency document titled "Home Health Certification and Plan of Care," dated 2/3/2021, and signed by the primary care physician. This document indicated the patient was to receive 400 ml (milliliter) bolus (given all at once) for 4 feeds/day. This document indicated the patient was to receive skilled nursing services 10-12 hours/day 3-5 days/week. Clinical record review on 3/9/2021, evidenced an agency document titled "Form: Physician - Physician Order Form," dated 2/8/2021, signed by the primary care physician. This document indicated the patient was to receive feedings through the g-tube (tube inserted through the abdomen that delivers nutrition directly into the stomach) with 300 ml for 3 feeds/day. The home health agency failed to update the plan of care to reflect the new verbal order to give a 300 ml bolus for 3 feeds/day. Clinical record review evidenced an agency document titled "Physician's Orders," dated 2/17/2021, signed by (registered nurse) RN B, Clinical Supervisor. This document stated "... D/C [discontinue] skilled nurse frequency New skilled nursing frequency: 8-12 hours day ... 3-5 days a week...." The home health agency failed to update the plan of care to reflect the new verbal order to change skilled nursing services to 8-12 hours/day 3-5 days/week. During an interview on 3/8/2021 at 3:30 p.m., the Clinical Supervisor indicated the plan of care provided was the current plan of care. During an interview on 3/10/2021 at 1:20 p.m., (Licensed Practical Nurse) LPN D, indicated there was a verbal order to change g-tube feedings from 400 ml bolus 4 feeds/day to 300 ml bolus 3 feeds/day. During an interview on 3/10/2021 at 10:17 a.m., LPN D, indicated they put in new orders ASAP [as soon as possible], which was almost always less than 24 hours after receiving them and these orders are reflected on the plan of care. 17-15-1(a)(7)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient's needs and involve the patient/caregiver in the coordination of care in 1 of 1 clinical record reviewed with psychiatric services provided. (#1) The findings include: Review of an agency policy, revised 6/5/17, titled "Coordination of Care" stated, "... Patient care will be coordinated with the patient, patient representative and all members of the health care team. ... All providers of care (physicians, pharmacies, DME [durable medical equipment] companies, therapy, etc) are encouraged to maintain open communication to ensure their efforts effectively complemented one another. All efforts should support and enhance patient care needs. Communication will be maintained through effective service coordination regarding changes in the patient's needs, services or care goals. When a situation occurs that requires action by another provider of services/care, it is the responsibility of the agency staff to contact the other provider to assure awareness of the situation. This contact should be documented in the patient's record...." Clinical record review on 3/8/2021 for patient #1, start of care 6/7/2011, evidenced an agency document titled "OASIS Recertification Assessment", dated 2/23/2021, and electronically signed by RN (registered nurse) C, which indicated the patient's diagnoses included, but were not limited to, congenital myopathies (genetic muscle disease). The patient's psychological status and behavior was assessed to include anxiety, sadness or depressed and difficulty coping with altered health status. Review of an agency document titled "Home Health Certification and Plan of Care" for certification period 3/4/2021 - 5/2/2021 indicated the patient's mental status was depressed. Review indicated the patient's medication included, but was not limited to, Lorazepam (a medication used to treat anxiety) twice a day as needed and Lexapro (a medication used to treat depression) daily. During an interview on 3/9/2021 at 11:24 a.m., RN C indicated the patient was seen by a psychiatrist weekly per the skilled nurse in the home, but the agency did not have any communication with the psychiatrist because the mom would not sign off on the consent to allow the agency to coordinate care with the psychiatrist. RN C indicated she was not sure what the interventions and services were for the patient's depression and anxiety because the agency was unable to coordinate care with the psychiatrist. RN C indicated there was no documentation the agency's plan of care had been provided to the psychiatrist. During an interview on 3/9/2021 at 12:20 p.m., the administrator indicated documentation would be provided regarding attempts to receive consent from the patient's mother to coordinate care with the patient's psychiatrist, but no additional documentation was provided. Clinical record review failed to evidence attempts to coordinate care with the psychiatrist regarding individualized care and services necessary to meet to the patient-specific needs as identified in the comprehensive assessment to include depression, anxiety and difficulty coping with altered health status. Review failed to evidence attempts to inform the patient's caregiver on the need to obtain consent to coordinate care with the psychiatrist.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the skilled nurse prepared the clinical notes appropriately in 1 of 3 clinical records reviewed with skilled nursing services. (#1) The findings include: Review of an agency policy, revised 9/21/2020, titled "Skilled Professional Services" stated, "... Skilled professional services are provided by a Registered Nurse or a Licensed Practical Nurse ... Professional Skilled Staff ... prepares clinical documentation ... The skilled professional will demonstrate competency in the skills necessary to provide care to a specific patient ...." Review of an agency policy, revised 11/12/19, titled "Documentation Standards" stated, "... Any person who makes entries will complete each entry by recording the following: ... All entries are: legible, complete, organized, current, meaningful and succinct. ... Documentation must be detailed, accurate, reflective of care/services provided ...." Review of an agency policy, revised 5/19/2020, titled "Cough Assist Machine [a non-invasive treatment to clear the airway when unable to cough or clear airway secretions effectively]" stated, "... Documentation ... Response/tolerance to therapy ... Cough effort ... Duration of treatment ... Quality of secretions ... suctioning, if appropriate ...." Review of an agency policy, revised 6/20/2020, titled "Tracheostomy [a hole created surgically in the neck and into the airway to deliver oxygen to the lungs] Tube Suctioning" stated, "... Documentation ... Pre and post procedure respiratory assessment ... Color, consistency, odor and amount of secretions ... Patient tolerance of the procedure ...." Review of an agency policy, revised 7/21/2020, titled "Gastrostomy (GT), Gastrojejunal (GJ) Tube Care and Management" stated, "... Flush tubing: ... GT [g-tube; a surgically created hole in the abdomen and into the stomach to provide medication, nutrition, fluid]: flush with ordered amount of water before/after medications ... with ordered amount of water. ... Document the procedure...." Review of a reference document titled "Development of Infant Feeding Skills" website, retrieved 3/16/2021 at https://wicworks.fns.usda.gov/wicworks/Topics/FG/Chapter2_DevelopmentofFeedingSkills.pdf indicated the suck and swallow reflex was seen from birth to 4 months of age. Clinical record review on 3/8/2021 for patient #1, start of care 6/7/2011, of an agency document titled "Home Health Certification and Plan of Care" for certification period 3/4/2021 - 5/2/2021, indicated the patient was 24 years old and was able to eat oral foods as tolerated. Review of untitled agency documents, identified by the clinical supervisor as skilled nurse visit notes, dated 2/22/2021, 2/23/2021, 2/24/2021, 2/25/2021, 2/26/2021, 3/2/2021, 3/3/2021, 3/4/2021 and electronically signed by RN H, indicated the patient's suck and latch reflex was assessed. Review of the note dated 2/22/2021, indicated the skilled nurse provided the cough assist treatment followed by suction of the tracheostomy and mouth. Review failed to evidence the skilled nurse documented the cough effort, duration of the cough assist therapy, quality of the secretions, patient tolerance of the cough assist treatment and suctioning per agency policy. Review of an untitled agency document, identified by the clinical supervisor as a skilled nurse visit note, dated 2/23/2021, and completed by RN I, indicated the RN flushed the patient's g-tube with water after administering medications, but failed to document the amount of the flush per agency policy. During an interview on 3/9/2021 at 11:29 a.m., RN C indicated she was unsure why the skilled nurse assessed the suck and latch reflex as it was not age appropriate for the patient and the patient was able to eat a regular oral diet with no problems. RN C indicated the RN should have documented how deep the tracheostomy suctioning was performed, the number of times the patient was suctioned and the color and amount of the secretions. RN C indicated the RN should have documented the amount of water flush was provided via the patient's g-tube. During an interview on 3/9/2021 at 11:29 a.m., the administrator indicated she had a list of documentation issues she needed to address with RN H to include the assessment of the suck and latch reflex.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the administrator employed qualified personnel. The findings include: Review of the agency policy revised 1/13/2020, titled "Location Management" stated "... All branches of the Company are to be under the direction of an Administrator (also known as Location Director or Area Director) ... whose primary responsibility is organization and direction of day-to-day operations ... The Location Director's responsibilities include: ... Employing qualified staff and ensuring utilization of staff with active/current licenses, credentials and personnel files...." Review of the agency policy revised 9/30/2019, titled "Personnel Records" stated "... Medical information and background check documents must be maintained in a separate file labeled "confidential...." A record review evidenced an undated agency document titled "... Aveanna Healthcare ... Location Job Description ... Administrator/Location Director ...." This document stated "... Manage the day to day operations of a AVEANNA location ... Job Responsibilities ... interview and hire the best qualified staff to fill open positions ...." A record review evidenced an email from Xchange Auto-Email to employee F, employee services supervisor, dated 2/9/2021. This document indicated a background check was conducted for (registered nurse) RN G and was eligible for employment. The document failed to provide the background information that was obtained for employee RN G. The Administrator failed to ensure RN G was qualified for the position. During an interview on 3/8/2021 at 1:30 p.m., the Administrator indicated corporate runs the background checks and only informs her if they find anything in the background check through email. During an interview on 3/8/2021 at 1:31 p.m., RN A, Administrator, indicated she cannot view background checks in the email. She indicated corporate makes a decision, not us.