Every finding on record at Marian Healthcare Services, LLC

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: AM = morning PM = evening RN = Registered Nurse SOC = Start of care Pt./ Pts. = Patient/Patients # = Number

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: A. Based on review of clinical records and staff interviews, it was determined the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. This was found in 5 of 7 (Pts. #2, 3, 4, 5 and 6) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 10/11/22 to 10/12/22 from 1:30 PM to 3:30 PM. Pt. #2. SOC 06/28/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry. Pt. #3. SOC 08/25/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry. Pt. #4. SOC 09/10/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry. Pt. #5. SOC 08/19/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry. Pt. #6. SOC 09/02/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry. 2. During an interview with the Agency Administrator on 10/13/22 from 10:00 AM to 11:30 AM, the Agency Administrator stated, the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in SOC comprehensive assessment. During the same interview, the Agency Supervisor confirmed the SOC comprehensive assessment/clinical record lacked an inquiry for the Pneumococcal Pneumonia and Influenza vaccines.

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: A. Based on a review of clinical records, Agency policy review and staff interview, it was determined the Agency failed to ensure a copy of the Discharge Summary was sent to the Physician. This was found in 1 of 2 (Pt. #6) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 8/18/22. Primary Diagnosis: Non-displaced Fracture of Lateral Malleolus of Right Fibula. The closed/discharged clinical record was reviewed on 10/12/22 at 9:30 AM. Physical Therapy note dated 10/5/22 indicated Pt .#6 was discharged from the Agency. The clinical record lacked documentation the Agency sent a copy of the Discharge Summary to the physician. 2. The Agency's policy titled "Discharge/Transfer/ Referral of Patients” required: "8. Discharge notes and summaries shall be written…when services are terminated… 9. The completed Discharge/Transfer Summary shall be sent to the patient’s primary care practitioner and/or other responsible healthcare professional(s) within the following time frames- Discharge: Within five (5) business days of the patient’s discharge…” 3. During an interview with the Agency Administrator and Agency Supervisor on 10/13/22 at 10:00 AM, the above findings were confirmed.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 5 of 7 (Pts. #3, 6, 2, 4 and 5) clinical record reviewed. 3. Pt. #2. SOC 6/28/22. Primary Diagnosis: Bilateral Osteoarthritis of Knee. The clinical record was reviewed on 10/11/22 at 1:30 PM. The record lacked the completion of the following forms: Admission Consents/Services Agreement, Notice of Medicare Non-Coverage, Influenza/Pneumonia Vaccine Questionnaire, Home Environment Safety Evaluation, and Insurance Verification. 4. Pt. #4. SOC 9/10/22. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 10/11/22 at 2:30 PM. The record included a form titled: "Advance Beneficiary Notice of Non-coverage (ABN)," signed by the Pt. and not completed/dated. The record also included the form “Notice of Medicare Non-Coverage,” signed by the Pt. and not completed/dated. The record lacked the completion of the following forms: Admission Consents/Services Agreement, Influenza/Pneumonia Vaccine Questionnaire, Home Environment Safety Evaluation, and Insurance Verification. 5. Pt. #5. SOC 8/19/22. Primary Diagnosis: Primary Lateral Sclerosis. The clinical record was reviewed on 10/11/22 at 3:30 PM. The record included a form titled: "Patient Discharge Instruction,” signed by the Pt. and not completed/dated. The record also lacked the completion of the following forms: Admission Consents/Services Agreement, Notice of Medicare Non-Coverage, Influenza/Pneumonia Vaccine Questionnaire, Home Environment Safety Evaluation, and Insurance Verification. 6. During an interview with the Agency Administrator on 10/13/22 from 10:00 AM to 11:30 AM, the Agency Administrator stated, the RN is required to complete the appropriate forms during admission as needed. During the same interview, the Agency Supervisor confirmed the forms were incomplete, not applicable and/or missing. Findings include: 1. Pt. #3. SOC 8/25/22. Primary Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 10/12/22 at 12:30 PM. The record contained a "Home Health Change of Care" document. The items/services, reason for change and the reason of the change were left blank. This document was signed by the Pt., but not dated. The record also contained the forms “Consent for Home Care Services and Agreement,” was signed by the Pt. but lacked entries for the Pt. Name and Medical Record Number. The record also contained the forms “Authorization for Release of Medical Information,” and “Consent to Share Personal Information.” The above-mentioned forms were signed by the Pt. but were not filled out. 2. Pt. #6. SOC 8/18/22. Primary Diagnosis: Non-displaced Fracture of Lateral Malleolus of Right Fibula. The clinical record was reviewed on 10/12/22 at 9:30 AM. The record contained a "Home Health Change of Care" document. The items/services, reason for change and the reason of the change were left blank. This document was signed by the Pt., but not dated. The record also contained the forms “Consent for Home Care Services and Agreement,” “Beneficiary Elected Transfer”, “Authorization for Release of Medical Information,” “Certificate of Self-Directed Care” and “Consent to Share Personal Information.” The above-mentioned forms were signed by the Pt. and dated with the SOC date but were not filled out.