Every finding on record at Med-Staff Home Health, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 1/31/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A standard survey for Medicare recertification for the home health provider was completed on 1/31/2024. The provider had 113 current patients.

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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, three of three home visit observations (Records/Patients #1, #2 and #3). This deficient practice has the potential to affect the home health provider's ability to ensure safe and effective use of medications for all patients served by the provider. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 0/12/2024 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and additional diagnoses of complications related to a bone marrow transplant, myeloblastic leukemia (a cancer of the blood cells) and idiopathic aseptic necrosis of the left femur (a bone condition that results from poor blood supply to an area of bone, causing localized bone death). The patient lived at home alone and had family who checked in on them throughout the week. Observation and interview on 01/30/2024 at 12:00 PM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The provider’s medication profile showed an order for calcium citrate (a mineral supplement) 250 milligrams (mg), take two tablets twice daily (BID). The patient was taking calcium carbonate 600 mg with vitamin D3 400 International Units (IU), one tablet daily; and - The patient stated that he/she was taking Senekot Laxative Gummies (senna leaf powder 34.8 mg) take four gummies up to twice daily as needed for constipation. The provider’s medication profile failed to contain this medication. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2024 with a primary diagnosis of diabetes (a group of diseases that results in too much sugar in the blood) and additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and end stage renal disease (a disease in which the kidneys no longer work as they should to meet the body’s needs). The patient goes to dialysis three times a week and recently moved back into his/her own home after an extended stay with one of his/her children. The patient has children and grandchildren who stay with the patient during the day. Observation and interview on 01/30/2024 at 10:10 AM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The patient had four docusate sodium (stool softener) capsules in an unlabeled medication bottle and stated that he/she took one capsule every day. The provider’s medication profile failed to contain this medication; and - The patient had a bottle of enteric coated aspirin 81 mg, take one tablet daily. The bottle showed a refill date of 01/23/2024 and the patient stated that he/she is taking this medication. The provider’s medication profile failed to contain this medication. During an interview on 01/31/2024, at 1:00 PM, the administrator stated that he/she expected the nurse to do medication reconciliation and look at the patient’s medications at every home visit and it is the registered nurse case manager’s responsibility to oversee medication reconciliation. Findings included: Review of the provider's policy, titled "MM – MEDICATION MANAGEMENT," revised August 2020 showed in part the following: - Upon admission, the Registered Nurse (RN), or Physical Therapist will complete an assessment of all medications the patient is taking, both prescription and over-the-counter (OTC) drugs and begin a medication profile; - All medications will be documented on the medication sheet as to the dose, frequency, route an indication. This includes prescription and non-prescription medication‘s, as well as home remedies as reported; - All medication in the home will be checked by the Agency nurse (RN) assigned to the respective patient's care for proper drug, dosage, allergies, potential adverse reactions, or side effects, drug-drug or food-drug interactions, indications, and contraindications; - Ongoing medication monitoring is collaborative and essential to ensure appropriateness and continuity of care or services and to identify the potential complications from the therapy being provided; and - The ongoing medication monitoring process includes information necessary for maintaining an accurate medication history and a complete medication profile and for ensuring the safety of the medication and administration process. The medication profile will be used to evaluate the patient’s current medication regimen. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 1/06/2024 after a skilled nursing facility stay for aftercare of a stage two pressure ulcer (skin injury caused by unrelieved pressure) of the right buttock and muscle weakness. The patient was alert and orientated times three (person, place, time). The patient lived at home with his/her spouse. The patient received skilled nursing and physical therapy services. Observation on 1/31/2024 at 11:10 AM, during the patient's home visit, showed the following: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state surveyor reviewed the provider's Medication Profile form with the patient’s spouse/caregiver, along with the patient present, with the following discrepancies; * Spiriva Respimat (bronchodilator) inhalation 2.5 micrograms (mcg)/actuation (act) one puff daily. The patient and patient's spouse stated he/she takes two puffs daily; * Omeprazole (acid reducer) 20 milligrams (mg) one capsule daily. The patient and patient's daughter stated he/she takes it as needed about three to four times per a week; * Vitamin D3 2000 IU (international units) one daily. The medication failed to be on the provider's list; and * Ketoconazole cream 2% as needed. The medication failed to be on the provider’s list.

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 policy review, record review, and interview, the home health provider failed to ensure that the patients received the home health services that were written on their individualized plan of care when the patients did not receive visits according to the visit frequency as ordered on the plan of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider's policy, titled "PC – PLAN OF CARE/CARE PLAN," revised March 2018 showed in part the following: - The agency provides care, treatment, and services for each patient according to the plan of care, treatment, and services; - All skilled services are furnished under the Plan of Care established by the physician. Qualified agency staff members administer drugs and treatments only as ordered by the physician; - The plan of care includes professional services, including the amount, frequency, and duration of service; - The homecare staff will implement the actions and interventions as identified in the Plan of Care; and - Patient care decisions and services to be provided are made based on the analysis of initial and ongoing assessments and physician orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 1/06/2024 after a skilled nursing facility stay for aftercare of a stage two pressure ulcer (skin injury caused by unrelieved pressure) of the right buttock and muscle weakness. The patient lived at home with his/her spouse/caregiver. The patient received skilled nursing services. Review of the Plan of Care (POC), dated 01/06/2024 to 03/05/2024, showed in part: - Skilled nurse (SN) one time a week for one week; and - Two times a week for eight weeks. Review of the clinical record showed: - The week of 01/07/2024 only one SN visit (order was for two) was completed. There failed to be any communication note or physician order for the missed visit; - The week of 01/14/2024 only one SN visit (order was for two) was completed. There failed to be any communication note or physician order for the missed visit; and - The week of 01/21/2024 only one SN visit (order was for two) was completed. There failed to be any communication notes or physician orders for the missed visits. During an interview on 01/30/2024 at 9:52 AM, the registered nurse/coder stated, he/she wrote an order at 6:33 AM today (01/30/2024) and dated it 01/09/2024 to change the order from one time a week times one week and two times a week times eight weeks to one time a week times nine weeks. During an interview on 01/31/2024 at 12:58 PM, the administrator stated clinical staff are to fill out a missed visit note and it is automatically sent to the primary care physician and they are to notify the supervisor verbally. During an interview on 01/31/2024 at 1:00 PM, the business office manager/assistant administrator stated every missed visit is faxed to the physician due to it goes to the fax que and the office staff fax it. The supervisor tries to make the visit up after being notified to move the visit accordingly.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on policy review, review of the provider’s quality assessment and performance improvement (QAPI) minutes and governing body meeting minutes and interview, the home health provider failed to provide documentation that showed the governing body provided oversight and approved of the provider’s QAPI program. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Program,” dated 04/2018, showed in part: - The provider’s governing body ensures that the program accurately reflects the organization and the provision of services; - The provider maintains evidence of its QAPI program efforts as required by state and federal regulation; - The program utilizes quality data, including data measures from the OASIS (Outcome Assessment Information Set), EMR (electronic medical records), other third-party data providers and other relevant data, as identified by the governing body, in its program; - The frequency and detail of the data collection is approved by the governing body; - The governing body is responsible for ensuring the following: * That an ongoing program for quality improvement and patient safety is defined, implemented and maintained; * That the QAPI efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness; and * That clear expectations for patient safety are established, implemented, and maintained. Review of the provider’s policy titled, “Governing Body,” dated 04/2018, showed in part, the governing body: - Has ultimate responsibility and legal authority for the operations of the home health agency; - Meets as often as necessary, but at least annually, and written meeting minutes are maintained; and - Responsibilities include, but are not limited to, an annual evaluation of the home health provider’s performance in relation to the overall performance improvement plan and activities. Review of the provider’s QAPI binder and governing body minutes on 01/31/2024 showed the QAPI notes and the governing body minutes failed to contain evidence that the governing body was monitoring and approving any QAPI activities. During an interview on 01/31/2024, at 10:25 AM, the administrator stated that the governing body meetings are not a formal program, he/she knows that they need to be, but it had not been high on his/her priority list.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on review of the Nurse Practice Act, clinical record review, home visit observation, and interview, the home health provider failed to ensure the clinicians provided services as ordered by the physician or allowed practitioner in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the provision of care for all the provider’s patients. Findings included: The Nursing Practice Act, Chapter 335, RSMo defined "Professional Nursing" at 335.016(15) as "the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family; (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; (c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medication and treatments; (d) The coordination and assistance in the delivery of a plan of health care with all members of a health team; and (e) The teaching and supervision of other persons in the performance of any of the foregoing." Review of the provider's policy, titled "PC – PLAN OF CARE/CARE PLAN," revised March 2018 showed in part the following: - The agency provides care, treatment, and services for each patient according to the plan of care, treatment, and services; - All skilled services are furnished under the Plan of Care established by the physician. Qualified agency staff members administer drugs and treatments only as ordered by the physician; - The plan of care includes treatments and specific types of services and equipment/supplies required to be provided for patient care; - The homecare staff will implement the actions and interventions as identified in the Plan of Care; and - Patient care decisions and services to be provided are made based on the analysis of initial and ongoing assessments and physician orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 1/06/2024 after a skilled nursing facility stay for aftercare of a stage two pressure ulcer (skin injury caused by unrelieved pressure) of the right buttock and muscle weakness. The patient lived at home with his/her spouse/caregiver. The patient received skilled nursing services. Review of the Plan of Care (POC), dated 01/06/2024 to 03/05/2024, showed in part: - The patient was admitted to home health services with a diagnosis of pressure ulcer of the right buttock, stage two and muscle weakness; - Frequency and duration of visits: * Skilled nurse (SN) 1wk1 (1 time weekly for 1 week), 2wk8 (2 times weekly for 8 weeks); and - Right buttocks pressure ulcer: cleanse with wound cleanser, cover with Aquacel (dressing for moderate to heavily exuding wounds) foam two times weekly and PRN (as needed) if soiled, CG (caregiver) to perform wound care in absence of SN. Observation on 1/31/2024 at 11:10 AM, during the patient's home visit, showed the following: - The skilled nurse stated the spouse/caregiver would demonstrate the wound care; - Barrier placed on the table with dressing supplies including Xeroform (fine mesh gauze dressing for use on low exudating wounds); and - The spouse performed the dressing change to the right buttock applying the Xeroform provided by the provider. The skilled nurse failed to ensure services were provided as ordered. Both registered nurses (RNs) on the visit confirmed the dressing used was Xeroform, on 01/31/2024. During an interview on 01/31/2024 at 2:16 PM, the administrator stated that there is no reason to use Aquacel on the wound now. The wound is closed now and the nurse probably got a new order for Xeroform and didn’t write the order.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on policy review, review of provider’s governing body minutes and interview, the home health provider failed to provide documentation that showed the governing body assumed responsibility for the overall clinical and financial operations of the home health and it’s quality assessment performance improvement program (QAPI). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Governing Body,” dated 04/2018, showed in part, the governing body meets as often as necessary, but at least annually, and written meeting minutes are maintained. The governing body is responsible for, but not limited to, the following: - Ultimate responsibility and legal authority for the operations of the home health agency; - The adoption, approval and updating of policies and procedures for the operation and administration of the provider; - Oversight of fiscal management of the annual operating budget; - The annual evaluation of the home health provider’s performance in relation to the written mission, purpose and objectives; - The overall performance improvement plan and activities; - The effectiveness of the provider’s administrative practices, policies, procedures, and management of information; and - Ensuring that all services provided are consistent with accepted standards of practice and in compliance with applicable law and regulation. Review of the provider’s governing body meeting minutes, on 01/31/2024, showed in part the following: - The governing body failed to hold a meeting in 2023; - A meeting note, dated 11/11/2022, and the purpose was to appoint a back-up director of clinical services and back-up administrator. No other business was discussed; - A meeting note, dated 09/15/2021, and the purpose was to appoint a back-up director of clinical services and no other business was discussed; and - A meeting note, dated 04/14/2021, showed the governing body discussed the home health operations, budget, management and QAPI (this was the last time overall operations were discussed and was approximately 34 months ago). During an interview on 01/31/2024, at 10:25 AM, the administrator stated that the governing body meetings are not a formal program, he/she knows that they need to be, but it had not been high on his/her priority list. Findings were reviewed with the administrator on 01/31/2024, at 2:30 PM. The administrator stated that he/she had not really been involved in the governing body meetings but, he/she will be actively involved going forward.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and review of Chapter 26 Home Health Agencies, 19 CSR 30-26.010 (1)(B)(2)(A and B)(3) Home Health Licensure Rules, the agency failed to provide annual Alzheimer's disease training, to one of six employee files reviewed (Employee/E3). This deficient practice has the potential to affect the safety of all patients served by the provider. Findings included: On 01/31/2024, at approximately 2:45 PM, the provider’s policy for employee Alzheimer’s training was requested. No policy was provided. Review of Chapter 26 Home Health Agencies, 19 CSR 30.26.010 (1) (B) (2) (A and B) (3) showed: (B) Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients, or consumers with Alzheimer's disease or related dementias; (2) Employees or independent contractors who do not provide direct care for, but may have daily contact with persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia; and (3) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. EMPLOYEE/E3: Review of the employee file on 01/30/2024 showed: - Hire date: 08/09/2022; and - Failed to show any yearly Alzheimer's/dementia training since 08/09/2022. During an interview on 01/31/2024 at 1:20 PM, the business office manager (BOM) / assistant administrator stated, E3 should have had the annual Alzheimer’s training with all the other annual trainings, but somebody must have pulled it out of the packet she makes the copies from.

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 interview, the home health provider failed to provide documentation that showed a complete discharge summary was sent to the patient’s primary physician in two of two discharge records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect the continuity of care for all patients discharged by the provider. Findings included: On 01/31/2024, at approximately 2:45 PM, the provider’s policy for patient discharge summary was requested. No policy was provided. RECORD/PATIENT #5: Review of the clinical record showed, in part, the following: - A physician order, dated 12/12/2023, to discharge per patient request; - A discharge assessment, dated 12/13/2023, that showed “physician notified of discharge summary availability”; and - The record failed to show evidence that the complete discharge summary was sent to the patient’s primary physician within five business days of the patient’s discharge. During an interview on 01/31/2024, at 1:00 PM, the business office manager stated that they send every discharge summary over to the patient’s primary physician and he/she would find the fax verification to prove it was sent. At 3:00 PM the business office manager approached the surveyors and stated that he/she cannot prove the discharge summaries were faxed to the physician because someone deleted two year’s-worth of faxes and he/she does not have any way to get them back. Findings included: RECORD/PATIENT #6: Review of the clinical record showed, in part, the following: - A physician order, dated 12/27/2023, to discharge patient; - A discharge assessment, dated 12/27/2023, that showed “physician notified of discharge summary availability”; and - The record failed to show evidence that the complete discharge summary was sent to the patient’s primary physician within five business days of the patient’s discharge.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and interview, the agency failed to address the use of volunteers in an emergency or other staffing strategies to address surge needs during an emergency. This deficient practice has the potential to affect the safety and care of all the agency's patients during an emergency. Findings included: Review of the agency's emergency preparedness plan failed to show any policies, procedures, or other documentation explaining the use of volunteers or other emergency staffing strategies to be used during the activation of the emergency plan. During an interview on 6/9/2021 at 9:14 AM, the administrator stated that the agency does not have volunteers and there was nothing in the emergency preparedness policies and procedures for volunteers.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and interview, the agency failed to develop and implement an emergency preparedness communication plan that included the names and contact information for all staff, entities providing services under contract, and the patient's physicians. This deficient practice has the potential to affect all patient's receiving home health services in the event of an emergency. Findings included: Review of the agency's emergency preparedness plan showed the agency failed to develop and implement an emergency preparedness communication plan that included a list of names for all staff, the entities providing services under contract and contact information for the patient's physicians. During an interview on 06/09/2021 at 09:14 AM, the administrator stated that was all there was for the emergency preparedness plan and the agency's emergency preparedness plan needed updated.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan, and interview, the agency failed to ensure their emergency preparedness communication plan included a clear method for sharing medical information about patients with other healthcare providers. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's emergency preparedness communication plan failed to include a method for sharing medical information about patients with other healthcare providers. The administrator did find a binder with patient's information but it had not been updated since April 2020. During an interview on 06/09/2021 at 09:14 AM, the administrator could not find where the emergency preparedness plan identified the method to share medical information about patients with other healthcare providers.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on observation and interview the agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that developed and maintained an emergency preparedness communication plan that included a means of providing information about the agency's needs and its ability to provide assistance. This deficient practice has the potential to affect the health, safety, and well-being of all patients and staff of the agency. Findings included: Review of the agency's Emergency Preparedness plan showed no documentation of a means of providing information about the facility's needs and its ability to provide assistance to the authority providing jurisdiction. During an interview on 06/09/2021 at 9:14 AM with the administrator, he/she was unable to verbalize an emergency preparedness communication plan that included a means of providing information about the agency's needs and its ability to provide assistance. No further information was provided.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on employee file review, and interview, the agency failed to ensure staff were provided emergency preparedness training annually for one (Employee #1) of five agency employee files reviewed. This deficient practice has the potential to affect the emergency preparedness practices for all agency staff. Findings included: EMPLOYEE #1 (E1): Review of the employee file showed: -Licensed as a registered nurse (RN); -Date of hire: 04/12/2021; and -No record of emergency preparedness training. During interview on 06/09/2021 at 4:16 PM, the administrator was unable to find Employee #1's emergency preparedness training.

An extended survey for Medicare certification for Med-Staff Home Health, LLC was completed on 06/14/2021. The agency had 85 current patients. One condition-level deficiency was identified at an immediate jeopardy (IJ) level as follows: - 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. An immediate jeopardy (IJ) level citation related to the likelihood of serious harm for twenty two current patients (Patient #2, #3, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) and potential for future harm to other patients was identified during the survey. The findings were confirmed as immediate jeopardy by the Centers for Medicare and Medicaid Services (CMS) Regional Office (RO) on 06/10/2021. On 06/10/21 at 4:19 PM, the administrator was informed verbally and in writing, via the IJ Template, of the findings identified at an immediate jeopardy level. A formal written removal plan was submitted by the agency prior to the survey exit. This removal plan was reviewed by the state agency and it was determined, at the time of the survey exit on 06/14/21, that a satisfactory removal plan had been initiated related to the immediate jeopardy findings. The removal plan addressed how the agency would ensure serious harm or likelihood of serious harm would not occur or reoccur. The IJ was removed based on review of the removal plan and related activities completed by the agency. The condition-level deficiency identified, 484.60- Care Planning, Coordination of Services, and Quality of Care, remains cited. Three additional condition-level deficiencies were identified during this survey: - 484.50 Condition of Participation: Patient Rights; - 484.58 Condition of Participation: Discharge planning; and - 484.110 Condition of Participation: Clinical records. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) - see Tag G788. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey. Five (5) standard level deficiencies were identified.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information. The agency failed to provide in writing, in advance of furnishing care, the following information: - The contact information for the home health agency's current administrator (G414); - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment (G434); - The patient has the right to be advised of the names, addresses, and telephone numbers of federal and state-funded entities that serve the area where the patient resides (G446); - The patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge. The agency may only transfer or discharge the patient if: * The agency determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired (G462); * The agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered (G464); * The agency must make efforts to resolve the problem (G466); * The agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge (G468); * The agency must document the problem and efforts made to resolve the problem (G470); and - Information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aid services that are at no cost to the patient (G490). The cumulative effect of these deficient practices resulted in the agency's inability to ensure that all patients and/or representatives were informed of their rights and responsibilities.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on policy review, observation, and interview, the agency failed to provide the patient and representative (if any) correct contact information for the current home health agency administrator, to receive complaints in three (Records/Patients #1, #2, and #3) of three home visits conducted. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all agency patients/representatives. Findings included: Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part the home health agency must provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: Contact information for the home health agency administrator's name in order to receive complaints. RECORD/PATIENT #1: During a home visit observation on 06/08/2021 at 11:10 AM, review of the admission packet information failed to show the current administrator's name, the previous administrator's name was listed. RECORD/PATIENT #2: During a home visit observation on 06/08/2021 at 10:30 AM, review of the admission packet information failed to show the current administrator's name, the previous administrator's name was listed. RECORD/PATIENT #3: During a home visit observation on 06/08/2021 at 1:00 PM, review of the admission packet information failed to show the current administrator's name, the previous administrator's name was listed. During an interview on 06/09/2021 at 1:55 PM, with the administrator and business office manager, the business office manager stated that they had just realized the previous administrator's name was on the patient folders. They had printed stickers for staff to put on the patient folders.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide written information regarding the patient's right to participate in, be informed about, and consent or refuse care, with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, establishing and revising the plan of care, the frequency of visits, expected outcomes, any factors that could impact treatment effectiveness, and any changes in the care to be furnished prior to providing services in, but not limited to, one (Record/Patient #7) of four applicable records for patients that received a courtesy visit by a licensed practical nurse prior to the registered nurse conducting a start of care or initial visit. This deficient practice has the potential to affect the immediate needs, knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part the patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to- *Completion of all assessments; *The care to be furnished, based on the comprehensive assessment; *Establishing and revising the plan of care; *The disciplines that will furnish the care; *The frequency of visits: *Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; *Any factors that could impact treatment effectiveness; and *Any changes in the care to be furnished. RECORD/PATIENT #7 Review of a weekend report dated 05/09/2021 at 8:25 PM, provided by the administrator on 06/10/2021 at 11:45 AM, showed licensed practical nurse (LPN) B wrote that he/she provided treatment to the patient's lower extremities. There was documentation of the patient's blood sugar, insulin dosage and frequency, weight and upcoming appointments. There was no documentation regarding this visit in the medical record and no consent was obtained prior to treatment. Review of the patient's medical record showed: -Start of care date 05/12/21 (three days after LPN-B provided a wound treatment); and -Consent for treatment was signed and dated 05/12/2021 (the consent for treatment was signed approximately three days the LPN visited the patient). During an interview on 06/10/2021 at 9:20 PM, LPN B said the following: -He/she was told by the agency to do courtesy visits with patients because there was only one RN to admit all of the patients; -When it is his/her weekend to be on call and a new patient is admitted he/she will provide a courtesy visit to the patient if the registered nurse (RN) was unable to admit the patient timely; - During the courtesy visit the LPN checks the patient's vital signs, reviews the medication list and writes a medication list and lets the patient know the RN would reconcile the medications, review orders with the patient, and lets the patient know the RN would do the start of care; -He/she was not allowed to have the patient sign a consent form because this must be done by the RN; -There was no orders for him/her to do the visit; -There is nowhere to document courtesy visits in the medical record and he/she sends a written report of the courtesy visit to RN A and clinical manager; and -He/she provided a visit to patient #7 the weekend of 05/07/2021 (no specific date given), there was no plan of care only the referral information. During an interview on 06/09/2021 at 2:25 PM, the administrator said he/she was not sure if a courtesy visit was done the weekend of 05/07/2021, the LPN's only e-mail the visit, it is not in the medical record. The LPN does a "quick look over" and if wound care is done they need consent from the patient to do wound care. The clinical manager has the e-mails of the courtesy visits and he/she is on medical leave. During an interview on 06/10/2021 at 12:00 PM, the administrator said; any new admission over the weekend the LPN that is on-call visits the new patient for continuity of care. He/she thought the LPN did the admission paperwork with the consent for treatment but didn't want to know if this wasn't being done because the RN should do the initial visit not the LPN. He/she was able to get in the clinical manager's office and find the e-mail of the courtesy visit.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include that the patient has the right to be advised of the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that serve the area where the patient resides and to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: The agency administrator provided an admission packet for review on 06/07/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show accurate information for the Federally-funded and State-funded entities that serve the area where the patient resides. The booklet provided a number for Center for Independent Living in St. Joseph, MO. The surveyor called the number provided on 06/07/2021 at 3:30 PM and was told, that St. Louis was not covered by this phone number. This number was on the wrong side of the state and covered nine counties in North West Missouri. The numbers provided for Aging and Disability Resource Center was for Albany and Cameron, Missouri. The surveyor called the number provided on 06/07/2021 at 3:39 PM and was told, that St. Louis was too far south and the St. Louis area was not covered by this phone number, that they covered 18 counties in North West Missouri. The surveyor was provided with a local number to call. The surveyor called the number provided on 06/07/2021 at 3:45 PM and it was local, located in Ballwin, MO and they covered St. Louis County. Review of the current patient rights information failed to include the current QIO organization. The agency listed Primaris as the current QIO organization for their area. The current QIO is Livanta LLC. On 06/09/2021 at 2:10 PM, the findings were reviewed with the agency administrator. The administrator agreed with the need to provide a local numbers for the agency patients.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure agency staff followed the policy and procedure related to discharging a patient for cause in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part: - The agency determines, under a policy set by the agency for the purpose of addressing discharge for cause that meets the requirement of paragraph of this section, that the patient (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency must do the following before it discharges a patient for cause: - Advise the patient, representative (if any), the physician (s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any) that a discharge for cause is being considered; - Make efforts to resolve the problem presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; - Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and - Document the problem (s) and efforts made to resolve the problem, and enter this documentation into its clinical records. Review of the transfer and discharge information provided to patient's upon admission to the agency showed: - Discharge for cause: There has been documented, unresolvable situation where the patient's (or other person in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the home health agency to operate effectively is seriously impaired. The agency will document its attempt to resolve this situation prior to discharge or transfer; and - The discharge information failed to include that the agency must do the following before it discharges a patient for cause: *Advise the patient, representative (if any), the physician (s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any) that a discharge for cause is being considered; and *Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care. RECORD/PATIENT #5: Review of a discharge summary dated 06/01/2021, completed by the occupational therapist (OT) showed: - Reason for discharge was, non-visit OASIS (outcome and assessment information set) discharge from agency per the agency's request; - Physician notified of discharge prior to discharge date, per agency policy and timeline; - Discharge from home health services; and - Physician notified of discharge summary availability. Review of the medical record showed no documentation regarding the circumstances that warranted the patient's discharge. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: - He/she had not been aware of the discharge, but understood it was due to his/her noncompliance and they discharged the patient for cause; and - The administrator agreed there should be documentation of what occurred leading up to the discharge.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to advise the patient/representative and the primary care practitioner that a discharge for cause was being considered in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part, the home health agency may only transfer or discharge a patient if: - The agency determines, under a policy set by the agency for the purpose of addressing discharge for cause that meets the requirement of paragraph of this section, that the patient (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency must do the following before it discharges a patient for cause: *Advise the patient, representative (if any), the physician (s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any) that a discharge for cause is being considered; Review of the transfer and discharge information provided to patient's upon admission to the agency showed in part: - Discharge for cause: There has been documented, unresolvable situation where the patient's (or other person in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the home health agency to operate effectively is seriously impaired. The agency will document its attempt to resolve this situation prior to discharge or transfer; and - The information failed to include that the agency must advise the patient, representative (if any), the physician (s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any) that a discharge for cause is being considered. RECORD/PATIENT #5: Review of a discharge summary dated 06/01/2021, completed by the occupational therapist (OT) showed: - Reason for discharge was non-visit OASIS (outcome and assessment information set) discharge from agency per the agency's request; - Physician notified of discharge prior to discharge date, per agency policy and timeline (the patient was discharged on 06/01/2021); - Discharge from home health services; and - Physician notified of discharge summary availability. Review of the medical record failed to show documentation that the patient/representative and primary care practitioner was advised that a discharge for cause was being considered. During an interview on 06/09/2021 at 10:10 AM, registered nurse (RN) A stated that they discharged the patient because the caregiver had problems with the licensed practical nurse (LPN) and was very disrespectful with the nurse. The discharge was on 06/01/2021. He/she still had to document "all of that". He/she had notes in his/her phone but not in the patient's chart. He/she tried to resolve the situation with the caregiver over the phone. He/she notified the physician and they were getting a new agency for the patient. During an interview on 06/09/2021 at 12:30 PM, the patient's caregiver stated that: - He/she said he/she wanted a different nurse, but they did not have anyone else; - He/she did not cancel the patient's services; and - He/she was informed of the discharge on 06/01/2021. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: - He/she had not been aware of the discharge, but understood it was due to his/her noncompliance, and they discharged the patient for cause; and - The administrator agreed there should be documentation of what occurred leading up to the discharge; and - There was not an order for discharge. During an interview on 06/09/2021 at 6:30 PM, the OT stated that: - He/she worked for an agency that contracted with the agency; and - He/she was told to discharge the patient, and they did not say why. During an interview on 06/10/2021 at 10:30 AM, the physician's patient care coordinator stated that: - The RN from the agency notified them of the patient's discharge on 06/01/2021; and - They said the discharge was due to the caregiver's behavior. During an interview on 06/10/2021 at 11:05 AM, the patient's physician stated that: - He/she did not have a lot of detail regarding the discharge but understood there were issues with the caregiver; and - When asked if he/she felt it was an appropriate discharge, the physician stated that his/her perspective is that they continue continuity of care with another agency, which they did.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure efforts were made/documented to resolve problems prior to the patient being discharged for cause in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part, the home health agency may only transfer or discharge a patient if: -The agency determines, under a policy set by the agency for the purpose of addressing discharge for cause that meets the requirement of paragraph of this section, that the patient (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency must do the following before it discharges a patient for cause: -Make efforts to resolve the problem presented by the patient's behavior, the behavior of other persons in the patient's home, or situation. Review of the transfer and discharge information provided to patient's upon admission to the agency showed in part: -Discharge for cause: There has been documented, unresolvable situation where the patient's (or other person in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the home health agency to operate effectively is seriously impaired. The agency will document its attempt to resolve this situation prior to discharge or transfer. RECORD/PATIENT #5: Review of a discharge summary dated 06/01/2021 completed by the occupational therapist (OT) showed the reason for discharge was non-visit OASIS (outcome assessment and information set) discharge from agency per the agency's request; Review of the medical record failed to show documentation of efforts to resolve problems before the patient was discharged. During an interview on 06/09/2021 at 10:10 AM, registered nurse (RN) A stated that: -They discharged the patient because the caregiver had problems with the licensed practical nurse (LPN) and was very disrespectful with the nurse. He/she let the physician know of the situation. He/she still had to document "all of that"; and -He/she had notes in his/her phone but not in the patient's chart. He/she tried to resolve the situation with the caregiver over the phone. During an interview on 06/09/2021 at 12:30 PM, the patient's caregiver stated that: -He/she said he/she wanted a different nurse, but they did not have anyone else; -He/she did not cancel the patient's services; and -He/she was informed of the discharge on 06/01/2021. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: -He/she had not been aware of the discharge, but understood it was due to his/her noncompliance and they discharged the patient for cause; and -The administrator agreed there should be documentation of what occurred leading up to the discharge. During an interview on 06/09/2021 at 6:30 PM, the OT stated that he/she was not aware of any behaviors or uncooperativeness. During an interview on 06/09/2021 at 6:45 PM the COTA (certified occupational therapy assistant) stated that he/she did not have any issues with the patient. During an interview on 06/10/2021 at 10:30 AM, the physician's patient care coordinator stated that: -The RN from the agency notified them of the patient's discharge on 06/01/2021; and -They said the discharge was due to the caregiver's behavior.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure they provided the patient/representative with contact information of community resources and other agencies that may provide care prior to discharging a patient for cause in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part: -The agency determines, under a policy set by the agency for the purpose of addressing discharge for cause that meets the requirement of paragraph of this section, that the patient (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency must do the following before it discharges a patient for cause: -Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care. Review of the transfer and discharge information provided to patient's upon admission to the agency showed: -Discharge for cause: There has been documented, unresolvable situation where the patient's (or other person in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the home health agency to operate effectively is seriously impaired. The agency will document its attempt to resolve this situation prior to discharge or transfer; and -The information failed to include that the agency must do the following before it discharges a patient for cause: *Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care. RECORD/PATIENT #5: Review of a discharge summary dated 06/01/2021, completed by the occupational therapist (OT) showed: -Reason for discharge was non-visit OASIS (outcome assessment and information set) discharge from agency per the agency's request; and -Physician notified of discharge prior to discharge date, per agency policy and timeline. Review of the medical record failed to show the agency provided the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: -He/she had not been aware of the discharge, but understood it was due to his/her noncompliance and they discharged the patient for cause; and -The administrator agreed there should be documentation of what occurred leading up to the discharge.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to document efforts to resolve problems prior to discharging a patient for cause, in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part, the agency must do the following before it discharges a patient for cause: -Document the problem (s) and efforts made to resolve the problem, and enter this documentation into its clinical records. Review of the transfer and discharge information provided to patient's upon admission to the agency showed in part: -Discharge for cause: There has been documented, unresolvable situation where the patient's (or other person in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the home health agency to operate effectively is seriously impaired. The agency will document its attempt to resolve this situation prior to discharge or transfer. RECORD/PATIENT #5: Review of a discharge summary dated 06/01/2021 completed by the occupational therapist (OT) showed the reason for discharge was non-visit OASIS (outcome and assessment information set) discharge from agency per the agency's request; Review of the medical record failed to show documentation of efforts to resolve problems prior to discharging the patient for cause. During an interview on 06/09/2021 at 10:10 AM,registered nurse (RN) A stated that: -They discharged the patient because the caregiver had problems with the licensed practical nurse (LPN) and was very disrespectful with the nurse; -He/she let the physician know of the situation -He/she still had to document "all of that"; and -He/she had notes in his/her phone but not in the patient's chart. During an interview on 06/09/2021 at 12:30 PM, the patient's caregiver stated that: -He/she said he/she wanted a different nurse, but they did not have anyone else; -He/she did not cancel the patient's services; -The LPN was confrontational; -He/she talked to a manager but did not know their name; and -He/she was informed of the discharge on 06/01/2021. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: -He/she had not been aware of the discharge, but understood it was due to his/her noncompliance and they discharged the patient for cause; and -The administrator agreed there should be documentation of what occurred leading up to the discharge. During an interview on 06/09/2021 at 6:30 PM, the OT stated that: -He/she was told to discharge the patient, and they did not say why; and -He/she was not aware of any behaviors or uncooperativeness. During an interview on 06/09/2021 at 6:45 PM the COTA (certified occupational therapy assistant) stated that he/she did not have any issues with the patient. During an interview on 06/10/2021 at 10:30 AM, the physician's patient care coordinator stated that: -The RN from the agency notified them of the patient's discharge on 06/01/2021; and -They said the discharge was due to the caregiver's behavior.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on review of the agency's current patient rights information, and home visit observation, the agency failed to include the patient right; information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services that are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations in three (Record/Patient #1, #2, and #3) of three home visit observations conducted. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency office manager provided an admission packet for review on 06/07/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to include; written information regarding the patient's right to be informed about information that must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 06/09/2021 at 2:10 PM, the findings were reviewed with the agency administrator. No additional information was provided.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and interview, the agency failed to have a registered nurse (RN) complete the initial assessment of the patient within 48 hours of the referral to home care, or on the physician ordered start of care date in, but not limited to, one (Record/Patient #3) of five full records reviewed and one (Record/Patient #7) partial record reviewed. This deficient practice has the potential to affect the immediate needs of all the agency's patients. Findings included: Review of the agency policy titled, "Admission Procedure," dated 04/2018, showed in part: -The home health screening will be completed within 48 hours of acceptance of the referral; -Once the home health screening is complete and it has been objectively determined the client meets the eligibility requirements, the admission process will proceed and an initial assessment will be completed by a registered nurse or physical therapist; -Following the Home Health Screening, during the admission process , prior to providing services, the patient/caregiver will be provided with a copy and verbal explanation of all required paperwork including consent for treatment; and -Based on the registered nurse/physical therapist's (PT) determination of the patient's eligibility for admission, the patient will be admitted for services or referred to alternate sources for care if needed. RECORD/PATIENT #3: Review of the hospital referral dated 04/29/2021, showed the patient was discharged on 04/29/2021 and had orders for home health. Review of the clinical record showed: -The hospital referral dated 04/29/2021 showed the patient was discharged on 04/29/2021 and had orders for home health; -The Start of care (SOC) assessment form dated 05/18/2021 and digitally signed by the registered nurse (RN) showed: *The physician ordered start of care date was documented as 05/18/2021; *Review of the narrative skilled intervention note showed the patient was discharged to home on 04/29/2021; *The SN made multiple phone calls and attempts to drive-by for visits to initiate the start of care; -There was no start of care assessment until 19 days after the referral; -There was no documentation to show the physician was notified of missed visits or that an order was obtained for the delay/change in the start of care from 04/29/2021 to 05/18/2021; -Review of a fax dated 05/18/2021 showed physician ordered start of care date 05/18/2021; and -There was no written POC as of 06/07/2021. During an interview on 06/09/2021 at 9:20 PM, RN A said the following: -They had the referral for Patient #3 for a long time and he/she would not open the door, they had the referral since 04/29/2021; -If the patient is non-compliant and refuses visits after a few tries he/she notifies the doctor and discharges the patient; -He/she notified the physician of missed visits and there was no order for a change in the start of care date; and -A physician's verbal order to start care is obtained the same day of the assessment. RECORD/PATIENT #7: Review of the hospital referral dated 05/07/2021, showed orders for home health to start 05/08/2021. Review of a weekend report dated 05/09/2021 at 8:25 PM, provided by the administrator on 06/10/2021 at 11:45 AM, showed licensed practical nurse (LPN) B went to the patient's home and provided treatment to the patient's lower extremities. There was documentation of the patient's blood sugar, insulin dosage and frequency, weight and upcoming appointments. There was no documentation to show a consent was obtained prior to treatment. Review of the clinical record showed a start of care assessment form dated 05/12/2021 and digitally signed by the registered nurse (RN). The documentation showed, the date of physician's start of care was 05/12/2021 (the RN did not provide a start of care assessment until 4 days after the referral). The record failed to include documentation/communication that the physician changed the start of care date from 05/07/2021 to 05/12/2021. Review of the clinical record failed to include a plan of care (POC) as of 06/07/2021. During an interview on 06/10/2021 at 9:20 PM, LPN B said the following: -He/she was told by the agency to do courtesy visits with patients because there was only one RN do admit all of the patients; -If it is his/her weekend to be on call and a new patient is admitted he/she will provide a courtesy visit to the patient; - During the courtesy visit the LPN checks the patient's vital signs, reviews the medication list and writes a medication list and lets the patient know the registered nurse (RN) would reconcile the medications, review orders with the patient, and lets the patient know the RN would do the start of care; -He/she was not allowed to have the patient sign a consent form because this must be done by the RN; -There was no orders for him/her to do the visit; -There is nowhere to document courtesy visits in the medical record and he/she sends a written report of the courtesy visit to RN A and clinical manager; and -He/she provided a visit to patient #7, there was no plan of care only the referral information. During an interview on 06/10/2021 at 12:00 PM, the administrator said any new admission over the weekend, the LPN that is on-call visits the new patient for continuity of care. He/she thought the LPN did the admission paperwork with the consent for treatment but didn't want to know if this wasn't being done because the RN should do the initial visit not the LPN. He/she expected the RN to complete the initial assessment within 48 hours of the patient's referral. If the patient refuses visits he/she would expect the physician to be notified and get orders to change the start of care date if needed.

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 policy review, record review, home visit observation, and interview, the agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Management," dated 04/2018, showed: -Upon admission, the registered nurse (RN) or physical therapist (PT) will complete an assessment of all medications the patient is taking, both prescription and over-the-counter drugs and begin a medication profile; -All medications will be documented on the medication sheet as to the dose, frequency, route, and indication. This includes prescription, non-prescription medications, as well as home remedies as reported; and -Medications ordered for the patient received at the time of referral are compared to those on the list created at the time of admission. Any discrepancies are reconciled and documented. RECORD/PATIENT #1: During the patient's home visit observation on 06/08/2021 beginning at 11:10 AM showed the following discrepancies with the agency's current medication profile: -The medication profile showed an order for vitamin D3 25 micrograms (mcg) (1000 UT (international units) one tablet daily and an order for cholecalciferol (vitamin D3) 25 mcg (1000 UT). The nurse stated the medications were the same and needed to delete one of the orders. The patient had a bottle of vitamin D3 2000 IU (international units) 50 mcg. The patient stated that he/she has taken this once a day for at least two years; -The medication profile showed an order for Novolog (insulin) flexpen 32 units twice a day after breakfast and lunch. The patient stated that he/she takes between 24 and 32 units depending on what his/her blood sugar was; -The medication profile showed an order for Jardiance (for diabetes) 25 milligrams (mg) one tablet daily. The patient's bottle dated 06/01/2021 showed 10 mg once daily. The patient stated that he/she used to have samples of 25 mg but has been taking 10 mg for about the last 1 ½ years; -The medication profile showed an order for insulin glargine 44 units at bedtime. The patient stated that he/she has told the physician that he/she takes this in the morning. He/she took 42 units this morning because his/her blood sugar was under 250. The directions on the box said to take at the same time every day; -The medication profile showed an order for Albuterol sulfate (bronchodilator) 108 mcg/act two inhalations as needed for shortness of breath. The patient stated that he/she has not taken this for four or five years; and -The medication profile showed an order for Symbicort (bronchodilator) inhalation 160-4.5 mcg/act two inhaled puffs twice a day. The patient stated that he/she has not taken this for four or five years. During an interview on 06/11/2021 at 10:48 AM, the administrator stated that staff look at all medication bottles including over-the-counter medications. They should clarify any discrepancies with the physician. If the physical therapist finds any discrepancies they called him/her or the physician. When changes occur, staff update the medication profile. They should ask about medication changes at each visit. If there have been changes, they should update the medication profile.

Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This CONDITION is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to meet the requirements of 484.58 Condition of Participation: Discharge Planning, when the agency: - Failed to implement an effective discharge planning process (G562); and - Failed to document/send all necessary medical information to the receiving facility or health care practitioner to ensure the safe and effective transition of care (G564). The cumulative effect of these deficient practices has the potential to affect the care of all patients served by the agency.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the patient's received effective discharge planning in one (Record/Patient #5) of two discharge records reviewed. This deficient practice has the potential to affect the post discharge needs for all patients served by the agency. Findings included: Review of the agency policy titled, "Discharge Planning and Discharge," dated 04/2018, showed in part: -The agency will maintain a process for the ongoing assessment of each patient's continuing care and discharge planning needs; -Each patient's specific needs are considered during the discharge planning process; -The patient/family/caregiver and physician will be active participants in the discharge planning process with the patient being notified consistent with regulatory requirements; -Discharge decisions are made objectively based on the unique condition of each individual patient; -The professional home care staff will be responsible for assisting the patient/family/caregiver to identify and provide for anticipated care needs after discharge from the agency; -The professional home care staff will provide education related to the patient's discharge throughout the course of care; -An order for discharge will be obtained for all patients discharged prior to the completion of their plan of care; -The case manager will complete a discharge summary and send a copy of the summary to the physician upon request (the policy failed to address the regulatory requirement that the discharge summary must be sent to the physician within five business days); -In addition to the discharge OASIS (outcome assessment and information set, a federally mandated assessment) form, a discharge summary will be completed within 48 hours of receiving notice of the discharge; -Valid reasons for termination of service by the agency include, but are not limited to, the following: *Treatment goals are attained, *No longer homebound by Medicare definition; *A change in the patient's condition warrants services or care not provided by the home health agency; *Patient requires continuous care over and above the intermittent care provided by the home health agency; *The patient and/or family are non-compliant with required care; *The patient leaves the service area; *The physician does not review and sign the plan of care at the required interval; *The patient expires; *The patient requests that services be terminated; *The patient no longer requires intervention; *There is a significant safety threat present to staff that is not resolved; *The patient or patient's representative fails to comply with the agreed financial obligations due to the agency; *If the payer refuses or ceases to grant prior authorization for visits; *A face to face certification is not received from the physician within the required timeframe's; and -The discharged patient's clinical record is to be completed within ten working days after discharge. Review of the agency policy titled, "Patient Rights and Responsibilities," dated 05/2018, showed in part, the home health agency may only transfer or discharge a patient if: -The transfer or discharge is necessary for the patient's welfare because the agency and the physician who is responsible for the home health plan of care agree the agency can no longer meet the patient's needs, based on the patient's acuity. The agency must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the agency's capabilities; -The patient or payer will no longer pay for the services provided by the agency; -The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the agency agree that the measurable outcomes and goals set forth in the plan of care have been achieved, and the agency and physician who is responsible for the home health plan of care agree that he patient no longer needs the agency's services; -The patient refuses services, or elects to be transferred or discharged; -The agency determines, under a policy set by the agency for the purpose of addressing discharge for cause that meets the requirement of paragraph of this section, that the patient (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate effectively is seriously impaired. The agency must do the following before it discharges a patient for cause: *Advise the patient, representative (if any), the physician (s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any) that a discharge for cause is being considered; -Make efforts to resolve the problem presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; -Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and -Document the problem (s) and efforts made to resolve the problem, and enter this documentation into its clinical records. Review of the transfer and discharge information provided to patient's upon admission to the agency showed in part: -Certain criteria must be met before a patient once accepted onto service, can be transferred or discharged from home health care services. These include: *The patient's care needs change to require more than intermittent services or require specialized services not provided by the agency. The agency will arrange a safe and appropriate transfer; *The patient or payer will no longer pay for services; *The patient's physician and the agency agree the patient has met their treatment goals as per the plan of care and no longer requires home health services; *The patient refuses services, or elects to be transferred or discharged; and *Discharge for cause: There has been documented, unresolvable situation where the patient's (or other person in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the home health agency to operate effectively is seriously impaired. The agency will document its attempt to resolve this situation prior to discharge or transfer. RECORD/PATIENT #5: Review of the plan of care dated 05/11/2021 showed diagnoses that included paraplegia (paralysis of the legs), stage 3 (full thickness skin loss) pressure ulcer of the sacral region, left hip, right hip and stage 2 (partial thickness skin loss) pressure ulcer of the left ankle and other site. Review of a discharge summary, dated 06/01/2021, completed by the occupational therapist (OT) showed: -Reason for discharge was non-visit OASIS discharge from agency per the agency's request; -Physician notified of discharge prior to discharge date, per agency policy and timeline; -Discharge from home health services; and -Physician notified of discharge summary availability. Review of the medical record showed no other information regarding the patient's discharge. During an interview on 06/09/2021 at 10:10 AM, the registered nurse (RN) A stated that: -They discharged the patient because the caregiver had problems with the licensed practical nurse (LPN) and was very disrespectful with the nurse. He/she let the physician know of the situation. He/she still had to document "all of that". He/she had notes in his/her phone but not in the patient's chart. He/she tried to resolve the situation with the caregiver over the phone. He/she notified the physician and they were getting a new agency for the patient; and -He/she had not finished the OASIS discharge. The discharge was on 06/01/2021. The caregiver did not want an LPN to be the nurse and wanted a new company. He/she notified the physician right away. During an interview on 06/09/2021 at 12:30 PM, the patient's caregiver stated that: -The agency discharged the patient when he/she sent pictures of blood in the urinary catheter to the RN; -He/she said he/she wanted a different nurse, but they did not have anyone else; -The physician at the hospital said the catheter was not all the way in; -He/she did not cancel the patient's services; -The LPN was confrontational; -He/she talked to a manager but did not know their name; and -He/she was informed of the discharge on 06/01/2021. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: -He/she had not been aware of the discharge, but understood it was due to his/her noncompliance and they discharged the patient for cause; and -The administrator agreed there should be documentation of what occurred leading up to the discharge; and -There was not an order for discharge. During an interview on 06/09/2021 at 6:30 PM, the OT stated that: -He/she worked for an agency that contracted with the agency; -He/she was told to discharge the patient, and they did not say why; -When asked if he/she thought the patient was ready for discharge, he/she only evaluated the patient and knew he/she needed a lot of help; and -He/she was not aware of any behaviors or uncooperativeness. During an interview on 06/09/2021 at 6:45 PM the COTA (certified occupational therapy assistant) stated that: -He/she did not feel the patient was ready for discharge; -He/she understood it had something to do with money; and -He/she did not have any issues with the patient. During an interview on 06/10/2021 at 10:30 AM, the physician's patient care coordinator stated that: -The RN from the agency notified them of the patient's discharge on 06/01/2021; -They said the discharge was due to the caregiver's behavior; -They referred the patient to another agency; -The caregiver requested no visits until 06/06/2021; -The physician saw the patient on 06/03/2021; and -The patient went to the hospital on 06/05/2021. During an interview on 06/10/2021 at 11:05 AM, the patient's physician stated that: -He/she did not have a lot of detail regarding the discharge but understood there were issues with the caregiver; -When asked if he/she felt it was an appropriate discharge, the physician stated that his/her perspective is that they continue continuity of care with another agency, which they did; and -When he/she saw the patient on 06/03/2021, the patient had scrotal swelling. It was hard to say the cause. It could be nutritional or a urinary tract infection but he/she did not think it was just due to a urinary infection. There were no issues with the patient's urinary catheter and the patient's wounds were doing good. He/she was not aware of any issues with placement of the catheter. He/she did not feel the home health agency contributed to the patient's hospitalization. During an interview on 06/11/2021 at 10:05 AM, the office manager stated that they did not have a discharge order from the physician. During an interview on 06/11/2021 at 10:45 AM, the administrator stated that he/she would expect staff to follow the transfer/discharge information provided to the patients. The nurse should get a discharge order from the physician, complete the discharge OASIS and send the discharge summary to the physician within five business days.

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 policy review, record review, and interview, the agency failed to ensure a discharge summary that included all necessary information pertaining to the patient's current course of illness and treatment, post-discharge goals of care and treatment preferences was sent to the patient's health care practitioner to ensure the safe and effective transition of care for one (Record/Patient #5) of two discharge records reviewed. Findings included: Review of the agency policy titled, "Discharge Planning and Discharge," dated 04/2018, showed in part: -An order for discharge will be obtained for all patients discharged prior to the completion of their plan of care; -The case manager will complete a discharge summary and send a copy of the summary to the physician upon request (the policy failed to address the regulatory requirement that the discharge summary must be sent to the physician within five business days); and -In addition to the discharge OASIS (outcome assessment and information set, a federally mandated assessment) form, a discharge summary will be completed within 48 hours of receiving notice of the discharge. RECORD/PATIENT #5: Review of the plan of care dated 05/11/2021 showed diagnoses that included paraplegia (paralysis of the legs), stage 3 (full thickness skin loss) pressure ulcer of the sacral region, left hip, right hip and stage 2 (partial thickness skin loss) pressure ulcer of the left ankle and other site. Review of a discharge summary dated 06/01/2021 completed by the occupational therapist (OT) showed: -Date completed and discharge date 06/01/2021; -Reason for discharge was non-visit OASIS discharge from agency per the agency's request; -Care summary showed evaluation, standardized testing, bilateral upper extremity strengthening, functional mobility training, optimal positioning, patient and caregiver education; -Current status was blank; -The summary failed to include a summary of wound care, the status of the patient's wounds at the time of discharge and current wound treatment; -Goals summary/outcomes showed non visit discharge per agency request; -Physician notified of discharge prior to discharge date, per agency policy and timeline; -Discharge from home health services; and -Physician notified of discharge summary availability. During an interview on 06/09/2021 at 10:10 AM, registered nurse A stated that: -He/she had not finished the OASIS discharge. The discharge was on 06/01/2021; and -A discharge summary is always sent to the physician. He/she did not know of a timeframe to send the summary to the physician. During an interview on 06/09/2021 at 6:30 PM, the OT stated that he/she sent the discharge summary to the personnel in the home health agency office and believed it alerts the agency to send the summary to the physician. During an interview on 06/10/2021 at 10:30 AM, the physician's patient care coordinator stated that: -The RN from the agency notified them of the patient's discharge on 06/01/2021; and -They did not have a discharge summary from the agency. During an interview on 06/11/2021 at 10:45 AM, the administrator stated that he/she would expect staff to follow the transfer/discharge information provided to the patients. The nurse should get a discharge order from the physician, complete the discharge OASIS and send the discharge summary to the physician within five business days. The discharge summary should include a summary of the patient's care.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, observation, and interview, the agency failed to: -Provide each patient an individualized written plan of care (G572); -Include all patient care orders on the plan of care (G576); -Ensure conformance with physician orders (G578); -Ensure drugs, services and treatments are administered only as ordered by a physician (G580); and -Coordinate care delivery to meet the patient's needs, and involve the patient, representative, and caregiver as appropriate in the coordination of services (G608). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

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 policy review, clinical record review, and interview, the agency failed to provide each patient with a written individualized plan of care (POC) that was established by the physician in, but not limited to, 17 (Records/Patients #2, #3, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21 ) of the 76 current agency patients that failed to have a written plan of care (POC). This systemic deficient practice has the potential to impact the safe delivery of care for all agency patients. Findings included: Review of the agency's policy titled, "Admission Procedure," dated 03/2018, showed in part the patient accepted for admission, will have a plan of care developed in collaboration with the appropriate agency care team, the patient/caregivers, and the physician within 72 hours of the initial assessment visit. Review of the agency's policy titled, "Plan of Care/Care Plan," dated 03/2018, showed in part the following: -Policy: The agency provides care, treatment, and services for each patient according to the plan of care, treatment, and services; -The scope of the patient's plan of care/care plan will be determined by the services provided, the status of the patient, with the collaboration of the patient's physician and the patient and/or caregiver; -The Registered Nurse (RN) or Physical Therapist will initiate a written Plan of Care for each patient within 24 hours of the initial assessment/admission visit; -Procedure: The foundation of each patient's Plan of Care is the analysis of the initial/admission assessment data; -All skilled services are furnished under the plan of care established by a physician. Qualified agency staff members administer drugs and treatments only as ordered by the physician; and -The plan of care is developed and executed in coordination with the patient's physician. It is based upon the physician's orders confirming that the patient requires the services specified in the plan. The completed plan of care establishes the patient's care priorities, provides direction to the clinical staff involved in the care, ensures avoidance of duplication of services, and ensures compliance with professional standards. Review of the agency's policy titled, "Physician Orders," dated 03/2018, showed in part the following: -Policy: The agency provides home health care services according to a physician's or another authorized individual's orders or prescriptions as required by law and regulation; -Orders and prescriptions are reviewed for appropriateness and accuracy prior to providing care; -The physician accepting responsibility for the home health services verifies all orders as well as patient's need for care/services by signing the Plan(s) of care; and -Physician orders will be documented on the plan of care (485) or verbal order forms. RECORD/PATIENT #2: Review of the physician order dated 05/25/2021 showed an order for the following: -Skilled nursing (SN) to initiate home health and establish a plan of care (POC) per discharge orders; -Arrange ordered therapies and assess the patient's initial medical status in the home setting. The patient requires a skilled nurse for observation and assessment; -The skilled nurse is to identify and instruct the patient on knowledge deficits regarding medications, diagnoses and safety; -SN to visit two times per a week for three weeks and one time per a week for six weeks; and -Physical therapy (PT) to evaluate and establish a home exercise program, promote improved ambulation, functional mobility and transfer skills, to increase strength, gait training, balance, safety in the home environment and modalities for pain control and to restore patient to maximum functional potential. Review of the clinical record showed a start of care assessment dated 05/25/2021. The clinical record failed to include documentation that the SN communicated with the patient's physician for approval/coordination of the orders. The clinical record did not include a POC as of 06/07/2021. During an interview on 06/07/2021 at 4:44 PM, the office manager stated there was no POC for patient #2. During an interview on 06/08/2021 at 9:00 AM, the office manager stated registered nurse (RN) A had completed the POC last night (06/07/21). The POC was provided and dated 05/25/2021 through 07/23/2021. RECORD/PATIENT #3: Review of the referral dated 04/29/2021 showed home health was requested for SN, physical therapy (PT), occupational therapy (OT) and speech therapy (ST). The verbal orders and signature section of the form were left blank. Review of the hospital approved referral for medical care dated 04/29/2021 showed: -The patient was discharged 04/29/2021 and patient has been referred to home care services; -Date service is projected to start-04/30/2021; -Duration 04/30/2021 through 07/30/2021; and -Frequency: SN four visits, PT four visits, OT four visits and ST four visits. Review of the clinical record showed a start of care assessment dated 05/18/2021 (19 days after the referral). The documentation failed to show the SN communicated/coordinated with the patient's physician for approval of the orders. The clinical record did not include a POC as of 06/07/2021. During an interview on 06/07/2021 at 4:44 PM, the office manager stated there was no POC for patient #3. During an interview on 06/08/2021 at 9:00 AM, the office manager said RN A had completed the POC last night. The POC was provided and dated 05/18/2021 through 07/16/2021. During an interview on 06/09/2021 at 9:20 PM, RN A stated the following: -He/she did not complete Patient #3's comprehensive assessment until he/she was asked to finish it on 06/07/2021; and -He/she dated the comprehensive assessment and POC 05/18/2021 instead of 06/07/2021 (date completed) because he/she thought all of the dates should match. RECORD/PATIENT #7: Review of the referral dated 05/07/2021 showed the patient had a diagnosis of a venous ulcer. Home health requested for skilled nursing and physical therapy, the verbal orders and signature section of the form was left blank. Review of the hospital approved referral for medical care dated 05/07/2021 showed: -Date service is projected to start-05/08/2021; -Duration 05/08/2021 through 08/08/2021; -Frequency: SN six visits and PT six visits; -Types of service: Evaluation and treatment and daily dressing changes; and -Skilled services: Wound care/dressing change. Review of the clinical record showed the start of care comprehensive assessment dated 05/12/2021 (4 days after the referral), and showed skilled nursing planned one time a week for six weeks. The documentation failed to show the SN communicated/coordinated with the physician for approval of these orders (the referral showed the patient required daily wound care). The clinical record did not include a POC as of 06/07/2021. RECORD/PATIENT #8: Review of the agency referral dated 05/18/2021 showed the patient was discharged from a skilled/rehabilitation facility on 05/18/2021. The section for home health services was left blank. The section for the verbal orders and signature was left blank. Review of the skilled/rehabilitation facility referral dated 05/18/2021 showed the patient was to discharge to home on 05/18/2021 with PT, OT and RN. Review of the clinical record showed the start of care comprehensive assessment dated 05/22/2021 (four days after the referral) showed SN two times a week for three weeks and then one time a week for six weeks, PT and social worker to evaluate and treat. The documentation failed to show that the SN communicated/coordinated with the physician for approval of these orders. The clinical record did not include a POC as of 06/07/2021. RECORD/PATIENT #9: Review of the agency referral dated 05/13/2021, showed the patient was discharged 05/15/2021. The section for home health services requested was blank. The verbal orders and signature section of the form was left blank. Review of the extended care and rehab facility referral dated 05/13/2021 showed the patient discharges to home on 05/15/2021. There was an order dated 05/15/2021 for home health with registered nurse (RN), PT and OT. Review of the clinical record showed the undated and incomplete start of care comprehensive assessment orders for discipline and treatments, rehabilitation potential, and discharge plans was blank. The documentation failed to show the skilled nurse communicated with the physician for orders. The clinical record did not include a POC as of 06/07/2021. RECORD/PATIENT #10: Review of the referral form dated 05/19/2021 showed home health services for skilled nursing. The verbal orders and signature section of the form was left blank. Review of a faxed physician order dated 05/19/2021 showed "to evaluate and treat nursing and aide". Review of the undated Orders for Discipline and Treatments on the Start of Care assessment showed skilled nursing one visit for one week, then two visits for two weeks, then one visit for six weeks. The home health aide frequency was blank. The documentation failed to show the skilled nurse communicated/coordinated with the physician for orders. The clinical record did not include a POC as of 06/07/2021. Review of the electronic medical record (EMR) with the office manager on 06/09/2021 at 4:30 PM, showed RECORDS/PATIENTS #11, #12, #13, #14, #15, #16, #17, #19, #20, and #21 all had a start of care that failed to include documentation that showed the skilled nurse communicated/coordinated with the physician for orders and all of the clinical records failed to include a plan of care (485) as of 06/09/2021. Review of patient #18 plan of care, dated 03/18/2021 to 05/16/2021 showed the comprehensive assessment was not completed and the clinical record did not include a POC as of 06/09/2021. During an interview on 06/09/2021 at 4:31 PM, the office manager stated there was no plan of care (POC) in the electronic medical record (EMR) for patient's #2, #3, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #19, #20, and #21. The recertification assessment for patient #18 was not completed and there was no plan of care in the EMR. During an interview on 06/09/2021 at 9:20 PM, RN A said the following: -He/she works per diem and is the only RN and there is two LPN's; -He/she case manages all the agency's patients; -He/she had personal obligations in May and had to put the agency on the "back burner," there was a lot of referrals in May and he/she was unable to initiate/complete the start of care assessments and is working to get caught up; -He/she gets a verbal order from the patient's physician at the start of care and that covers the patient until the plan of care is completed; and -If he/she is behind and has not developed the POC for the LPN he/she gives the LPN a verbal report. During an interview on 06/10/2021 at 8:52 PM, LPN C stated the following: -RN A develops the plan of care and does the comprehensive assessment; -RN A will send a report or talk on phone to let the LPN know what the patient needs/treatments; -RN A doesn't always get the POC done quickly; -LPN A can look at the patient's diagnosis and do teaching; -Provide medication teaching from looking at the medication list; and -The POC is helpful and until it is completed he/she can teach with diagnosis and knowing medication list and diet. During an interview on 06/10/2021 at 9:20 PM, LPN B stated the following: -By the time RN A completes the POC and the clinical manager and quality assurance put in their notes, the POC usually takes three to four weeks to be available for staff to view; -His/her impression is RN A is verifying orders at the start of care and "surely" the company wouldn't send him/her out to do skilled visits without orders; -When he/she gets report from RN A with orders he/she is assuming RN A received verbal orders and verified orders; and -When he/she takes care of another nurse's patient he/she would get report from that patient's nurse if the POC hasn't been developed. During interview on 06/09/2021 at 1:37 PM and 4:26 PM, the administrator stated: -RN A is behind in his/her assessments; -The referral is not the signed orders from the physician; -It was expected that the comprehensive assessment and POC would be completed and developed quickly; -He/she would have to refer to the agency's policy for timeframe's; -When the comprehensive assessments are complete the information floats to the plan of care; and -The assessment goes to the coder and he/she was unsure who generates the POC.

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 policy review, record review, and interview, the agency failed to ensure that all patient care orders were included on the plan of care (POC) for one (Record/Patient #5) of two plans of care for the five full records reviewed (three of the five full records failed to have a plan of care). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care/Care Plan," dated 04/2018, showed in part: -The agency provides care, treatment, and services for each patient according to the plan of care, treatment, and services; -The registered nurse (RN) or physical therapist (PT) will initiate a written POC for each patient within 24 hours of the initial assessment/admission visit; -The care planning process will be individualized to address each patient's unique problems, needs, goals, and the specific care or services to be provided; -Qualified staff members administer drugs and treatments only as ordered by a physician; -The POC includes in part, treatments and therapy services; and -The POC is developed and executed in coordination with the patient's physician. It is based upon the physician's orders confirming that the patient requires the services specified in the plan. RECORD/PATIENT #5: Review of the physician referral dated 05/11/2021 showed an order for skilled nursing (SN) and PT. Review of the comprehensive assessment dated 05/11/2021 under the section for orders for discipline and treatments showed: -SN to change the patient's urinary catheter using a 16 french (size of catheter)/10 milliliter (ml) balloon (a balloon is inflated to hold the catheter in place) when next due; -Catheter flush/irrigation as needed for complications with 50-60 ml of sterile normal saline; -SN may replace catheter as needed for complications; and -Teach care of indwelling catheter. Review of the POC dated 05/11/2021 showed no orders regarding the urinary catheter and no orders for PT. During an interview on 06/09/2021 at 1:40 PM the administrator stated that the POC should include catheter changes, the size of the catheter and balloon, flushing orders and education. During an interview on 06/11/2021 at 10:40 AM, the administrator stated that he/she would expect a PT evaluation order to be included on the POC.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to conform with physician orders when the treatments documented did not follow the orders on the plan of care (POC) and the agency failed to provide a physical therapy (PT) evaluation as ordered by the physician in one (Record/Patient #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Physician Orders," dated 04/2018, showed in part: - All physician change orders will be written on a physician verbal order form or within the EMR (electronic medical record) and signed by the physician; - Physician orders will be documented on the POC or verbal order forms; - Telephone/verbal orders will be recorded immediately by the licensed person receiving the order and read back for verification of accuracy; and - The original copy of the verbal/telephone order will be sent to the physician for his/her signature and a copy will be kept in the clinical record. RECORD/PATIENT #5: Review of the physician referral dated 05/11/2021 showed an order for skilled nursing (SN) and PT. Review of the POC dated 05/11/2021 showed: - SN three times a week to assess pressure injury stage 3 (full thickness skin loss) wound to sacrum (close to the tailbone) every visit until healed. SN to perform wound care using aseptic technique, cleanse with Dakins ¼ strength (antimicrobial solution) and gauze and cover with ¼ Dakins soaked gauze; - SN to assess and perform wound care to pressure injury stage 3 to the left hip every visit. SN to cleanse with wound cleanser and gauze, apply Santyl (removes dead tissue to promote healing) to wound bed followed by calcium alginate (maintains a moist environment to promote healing), cover with gauze, ABD (large absorbent) pad and secure with tape; - SN to assess and perform wound care to pressure injury stage 3 to the right hip. SN to cleanse with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate, cover with gauze, ABD pad and secure with tape; - SN to assess and perform wound care to pressure injury stage 2 (partial thickness skin loss) to the left lateral (side) ankle every visit. SN to cleanse with wound cleanser and gauze, cover with optifoam (foam dressing) 4 x 4 dressing twice a week; - SN to assess and perform wound care to pressure injury stage 2 to the right medial knee. SN to cleanse with wound cleanser and gauze, cover with optifoam (foam dressing) 4 x 4 dressing twice a week; - Verbal POC called into doctor; and - The POC failed to include an order for PT. Review of the SN visits showed: - On 05/12/2021 the SN performed wound care (did not include what wound care was provided) and instructed the caregiver on wound care, proper turning and repositioning, and skin assessment on bony prominences; - On 05/14/2021 wound care provided per order. Renee (unsure if this meant right knee) cleansed with wound cleanser, applied Xeroform (non-adherent dressing) with border gauze, left thigh cleansed with wound cleanser, apply alginate, cover with dressing , L (did not specify location) cleanse with wound cleanser, apply Santyl/Xeroform and cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with a dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant), no dank (unsure if this meant Dakins) in home as on admission orders. (These orders were different from the POC orders and the POC orders did not include an order for the left thigh) Call placed to the physician's office for clarification. SN performed wound care per orders in admission/transfer notes; - On 05/17/2021 wound care per order. Renee cleansed with wound cleanser,applied Xeroform with border gauze, left thigh cleansed with wound cleanser, apply alginate, cover with dressing, L (did not specify location) cleanse with wound cleanser, apply Santyl/Xeroform and cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with a dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant), no dank (unsure if this meant Dakins) in home as on admission orders. Call placed to the physician's office for clarification. Spoke with the physician's patient care coordinator, clarified wound care orders, verbally reviewed orders for wound care that is attached from the skilled nursing facility. The patient care coordinator stated to continue the wound care orders, and he/she is ordering the Santyl and Dakins to be delivered to the patient. Wound care performed per orders; - On 05/19/2021 wound care per order. Renee cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog applied, no dank is in home on admit orders. Call to physician's office for clarification; - On 05/21/2021 wound care per order. Renee cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog applied, no dank is in home on admit orders. Call to physician's office for clarification. SN performed wound care as ordered. Wounds appear cleaner, scant drainage, no odor, appearance improving; - On 05/24/ 2021 wound care per order. Renee cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog applied, no dank is in home on admit orders. Call to physician's office for clarification; - On 05/25/2021 wound care per order: cleanse with wound cleanser, apply Xeroform, cover with border gauze (did not say what location this was), Left thigh cleanse with wound cleanser, apply alginate, cover with dressing. L cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog applied no dank is in home on admit orders. Call to MD office for clarification; - On 05/28/2021 wound care per order: cleanse with wound cleanser, apply Xeroform, cover with border gauze (did not say what location this was). Left thigh cleanse with wound cleanser, apply alginate, cover with dressing. L cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog applied no dank is in home on admit orders. Call to MD office for clarification. The SN performed wound care as ordered; - The wound care documented by the agency staff was different then the orders on the plan of care; and - The clinical record failed to include written interim physician orders for the wound care/treatments documented by the nurse. Review of the record showed no PT visits were provided. During an interview on 06/09/2021 at 12:58 PM, licensed practical nurse (LPN) C stated that: - The POC orders were not in the system in the beginning; - There was a wound care worksheet, but it had not been completed; and - He/she called the physician's office for orders and went step by step with what the physician ordered. During an interview on 06/09/2021 at 1:40 PM, with the administrator and office manager, the administrator stated that: - The referral was not signed orders from the physician; - The nurse should get the POC out right away; and - The office manager said their rule was to get the POC out in 24 hours. During an interview on 06/10/2021 at 9:28 AM, the office manager could not find information regarding the PT order. PT was never started for the patient. During an interview on 06/10/2021 at 11:05 AM, the patient's physician said he/she usually ordered both PT and occupational therapy (OT) for patients. He/she saw the patient on 06/03/2021 and his/her wounds were doing good. During an interview on 06/11/2021 at 9:10 AM, the office manager said they had been sending one therapy discipline in at at time. It would depend on whether the nurse felt PT or OT was was needed more. If OT was in the home and they felt the patient still needed PT, then PT would go out. There was no documentation the physician was notified of this. During an interview on 06/11/2021 at 10:40 AM, the administrator stated that he/she would have expected a PT evaluation to be ordered. If both OT and PT were ordered, then they should send both.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the agency failed to ensure treatments were administered only as ordered by the physician in, but not limited to, one (Record/Patient #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Physician Orders," dated 04/2018, showed in part: -All physician change orders will be written on a physician verbal order form or within the EMR (electronic medical record) and signed by the physician; -Physician orders will be documented on the plan of care (POC) or verbal order forms; -Telephone/verbal orders will be recorded immediately by the licensed person receiving the order and read back for verification of accuracy; and -The original copy of the verbal/telephone order will be sent to the physician for his/her signature and a copy will be kept in the clinical record. RECORD/PATIENT #5: Review of a faxed referral form (undated) from the patient's skilled nursing facility showed: -The patient was to discharge to home on 04/30/2021; -An order for calcium alginate (maintains a moist wound environment to promote healing), gauze sponges and cover with bordered gauze island dressing to the left lateral thigh one time a day; -Apply Santyl (removes dead tissue to promote healing), Xeroform gauze (non-adherent dressing), gauze sponges, secure in place with gauze roll to the left ankle one time a day; -Pressure wound left buttock. After cleansing with normal saline/wound cleanser apply Xeroform gauze, gauze sponges and bordered island gauze one time a day; -Sacrum (close to the tailbone) wound apply Dakins (antimicrobial solution) soaked gauze sponges and cover with bordered gauze island two times a day; -Medihoney (antimicrobial) wound dressing paste to right hip (frequency not documented); and -Maintain #20 (size of catheter) coude catheter (has a bent tip to help get around any blockages). Change every month and as needed. The order did not include what size balloon to use. Review of an agency patient information form showed: -04/30/2021, the patient does not have a physician; -05/03/2021, names a physician who could not take the patient; -05/05/2021, the visiting physician association will have a physician see the patient; and -05/10/10, the visiting physician will sign for the patient. Review of the comprehensive assessment dated 05/11/2021 showed: -Skilled Nurse (SN) to change the patient's urinary catheter using a 16 french/10 milliliter (ml) balloon when next due; -Catheter flush/irrigation as needed for complications with 50-60 ml of sterile normal saline; -SN may replace catheter as needed for complications; -Right inner knee pressure ulcer stage 2 (partial thickness skin loss) that measured 2.0 x 1.3 x 0.0 centimeters (cm), wound bed red, scant serous (clear, watery) drainage with no odor, cleansed with wound cleanser and gauze, cover with optifoam (foam dressing) twice a week; -Left lateral (side) ankle pressure ulcer stage 2 that measured 3.0 x 1.9 x 0.1 cm, wound bed red, scant serous drainage with no odor, cleansed with wound cleanser and gauze, cover with optifoam 4 x 4 dressing twice a week; -Right hip pressure ulcer stage 3 (full thickness skin loss) that measured 1.1 x 1.2 x 0.3 cm, wound bed red, moderate serosanguinous (pale red or pink that appears as the wound is trying to heal) drainage with no odor, cleansed with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate, cover with gauze, cover with ABD (large, absorbent) pad, secure with tape three times a week, caregiver to perform the other four days; -Left hip pressure ulcer stage 3 that measured 3.0 x 1.3 x 0.5 cm with moderate serosanguinous drainage with no odor, tunneling 4.5 cm at 5 o'clock position, cleansed with wound cleanser, apply Santyl to wound bed, pack with calcium alginate rope, cover with gauze, cover with ABD pad, secure with tape three times a week, caregiver to perform the other four days; and -Sacrum pressure ulcer stage 3 that measured 8.0 x 6.0 x 0.2 cm, small amount of bloody drainage with no odor, cleansed with Dakins 1/4 strength and gauze, cover with 1/4 strength Dakins soaked gauze three times a week, caregiver to perform the other four days. Review of the POC dated 05/11/2021 showed: -Diagnoses that included paraplegia (paralysis of the legs), stage 3 pressure ulcer of the sacral region (close to the tailbone), left hip, right hip and stage 2 pressure ulcer of the left ankle and other site; -SN three times a week to assess pressure injury stage 3 wound to sacrum every visit until healed. SN to perform wound care using aseptic technique, cleanse with Dakins ¼ strength and gauze and cover with ¼ Dakins soaked gauze; -SN to assess and perform wound care to pressure injury stage 3 to the left hip every visit. SN to cleanse with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate (did not include to pack wound as documented on the comprehensive assessment), cover with gauze, ABD pad and secure with tape; -SN to assess and perform wound care to pressure injury stage 3 to the right hip. SN to cleanse with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate, cover with gauze, ABD pad and secure with tape; -SN to assess and perform wound care to pressure injury stage 2 to the left lateral ankle every visit. SN to cleanse with wound cleanser and gauze, cover with optifoam 4 x 4 dressing twice a week; -SN to assess and perform wound care to pressure injury stage 2 to the right medial knee. SN to cleanse with wound cleanser and gauze, cover with optifoam 4 x 4 dressing twice a week; and -No orders related to the urinary catheter. Review of the SN visits showed: -On 05/12/2021 the SN performed wound care (did not include what wound care was provided) and instructed the caregiver on wound care, proper turning and repositioning, and skin assessment on bony prominences; -On 05/14/2021 wound care provided per order. Renee (unsure if this meant right knee) cleansed with wound cleanser, applied Xeroform with border gauze, left thigh cleansed with wound cleanser, apply alginate, cover with dressing , L (unsure of what location this was) cleanse with wound cleanser, apply Santyl/Xeroform and cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with a dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant), no dank (unsure if this meant Dakins) in home as on admission orders. (These orders were different from the POC orders and the POC orders did not include an order for the left thigh) Call placed to the physician's office for clarification. SN performed wound care per orders in admission/transfer notes; -On 05/17/2021 wound care per order. Renee (unsure if this meant right knee) cleansed with wound cleanser,applied Xeroform with border gauze, left thigh cleansed with wound cleanser, apply alginate, cover with dressing, L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform and cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with a dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant), no dank (unsure if this meant Dakins) in home as on admission orders. Call placed to the physician's office for clarification. Spoke with the physician's patient care coordinator, clarified wound care orders, verbally reviewed orders for wound care that is attached from the skilled nursing facility. The patient care coordinator stated to continue the wound care orders, and he/she is ordering the Santyl and Dakins to be delivered to the patient. Wound care performed per orders. The GU section showed Foley catheter change 05/17/2021 with a 20 French, 10 cc catheter. Foley catheter changed via sterile technique 20 french cause (unsure if this meant coude) with yellow urine return (the record showed no physician order for this). SN provided teaching to caregiver regarding turning and repositioning, attempted teaching on wound care but was busy. Instructed on the use of Dawkins (Dakins), reviewed orders as to what to do for each wound; -On 05/19/2021 wound care per order. Renee (unsure if this meant right knee) cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure of what this meant) applied, no dank (unsure of what this meant) is in home on admit orders. Call to physician's office for clarification. SN performed wound care as ordered. SN continued teaching positioning in bed, use of pillows to relieve pressure off bony prominences; -On 05/21/2021 wound care per order. Renee (unsure if this meant right knee) cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure of what this meant) applied, no dank (unsure of what this meant) is in home on admit orders. Call to physician's office for clarification. SN performed wound care as ordered. Wounds appear cleaner, scant drainage, no odor, appearance improving. Urine cloudy with noted sediment. SN placed tubing correctly to drain to gravity, provided patient education on tubing placement. SN educated on proper fluids to consume. Patient states he/she drinks a lot of caffeinated beverages. SN educated on effects of too much caffeine and encouraged patient increase water intake. Spoke to the caregiver over the phone, educated on signs and symptoms of urinary tract infection, increase patient intake of proper fluids, report any changed urine appearance, odor, elevated temperature and change in mental status; -On 05/24/ 2021 wound care per order. Renee (unsure if this meant right knee) cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure of what this meant) applied, no dank (unsure of what this meant) is in home on admit orders. Call to physician's office for clarification. Conferenced with the physician's patient care coordinator and obtained an order to irrigate the catheter (this order was not found in the medical record). The SN assessed 600 milliliters (ml) of yellow urine in the closed drainage bag. The patient's incontinent brief was damp. The caregiver reported by phone the incontinent brief was very wet that morning. The catheter tubing was noted to be upward and over the top of the patient's brief and over the top of the right lower extremity with the patient laying on his/her left side. The SN irrigated the catheter with 60 cc (cubic centimeters) of normal saline per physician order without difficulty. The SN educated the patient on proper positioning of the tubing and on change of position the need to move the tube with the drainage bag to the other side of the bed. The patient was very reluctant to accept the instruction. The SN educated the patient on the action of draining urine and the patient verbalized he/she will attempt compliance; -On 05/25/2021 wound care per order: cleanse with wound cleanser, apply Xeroform, cover with border gauze (did not say what location this was), Left thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure of what this meant) applied no dank (unsure of what this meant) is in home on admit orders. Call to MD office for clarification. Received a call from the occupational therapy assistant (OTA) of need to assess catheter. Upon arrival, assessment revealed 75 ml in closed drainage bag. Patient laying on five saturated disposal pads. The catheter was coiled inside the incontinent brief with dried bowel movement in the brief. The SN cleansed the patient and provided clean padding and brief. The SN placed the catheter position and noted urine draining. The patient requested the catheter be changed as he/she is convinced that the catheter is not working. The SN changed the catheter via sterile technique with 150 ml of clear, yellow urine return. The SN performed wound care, continued teaching on proper placement of tubing and closed drainage bag. The patient is in the home from early morning to later in the PM as the caregiver works. The caregiver states he/she is in the process of possibly getting private duty through the veteran's administration. The SN attempted education to caregiver on proper catheter care, but was unable to participate due to being busy; -On 05/28/2021 wound care per order: cleanse with wound cleanser, apply Xeroform, cover with border gauze (did not say what location this was), Left thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure of what this meant) applied no dank (unsure of what this meant) is in home on admit orders. Call to MD office for clarification. SN performed wound care as ordered. Upon arrival SN assessed catheter function and placement. The patient continues to keep the catheter tubing upwards and over the top of the lower extremity. The patient declined teaching on proper catheter care. SN educated the patient on catheter drainage to gravity and that catheter changes weekly are not healthy. The patient verbalized understanding. SN attempted teaching on repositioning self every two hours to relieve pressure and patient declined. The SN educated the patient regarding communication with the OT in regards to pressure on feet and pressure points. The OT requested a wedge and heel protectors. The patient stated he/she will not use heel protectors and will consider using the wedge. The patient is alone nine to ten hours daily. The caregiver leaves some food items and fluids on the bedside table, and the patient used the trapeze to move him/herself in bed but primarily remains on the right side per choice. -The same wound care verbiage was carried over visit to visit under the skin comment section; -The wound care documented was different from the wound care documented as physician ordered on the POC dated 5/1/21. During an interview on 06/09/2021 at 10:10 AM, the RN A stated that: -He/she believed he/she used the wound care orders from the skilled facility; -He/she would call the physician to obtain catheter orders; -He/she added the catheter orders two days ago after the coder told him/her the orders were not on the POC; and -He/she would expect an order to be written for the 20/10 cc coude catheter. During an interview on 06/09/2021 at 12:58 PM, licensed practical nurse (LPN) C stated that: -He/she did wound care and changed the patient's catheter twice and provided teaching; -The POC, which includes the physician orders were not in the system in the beginning; -There was a wound care worksheet, but it had not been completed; -He/she called the physician's office for orders and went step by step with what the physician ordered; -He/she changed the catheter on 05/17/2021. The orders were in an attachment. The clinical manager had showed him/her how to look at the orders in the attachment from the skilled facility; -He/she had talked with the physician's patient care coordinator about the catheter leaking. He/she said to irrigate and change the catheter again. He/she found the order in an attachment from the skilled nursing facility the patient was transferred from. The physician went along with what was in the orders from the facility. He/she did not have any trouble changing the catheter. The clinical manager ordered the catheters for the patient. During an interview on 06/09/2021 at 1:40 PM, with the administrator and office manager, the administrator stated that: -The POC should include orders for catheter changes, size of catheter, balloon size of catheter, flushing of the catheter; -He/she would expect orders to be written for catheter changes including the size of the catheter and flushing orders; -The referral was not signed orders from the physician; -The nurse should get the POC out right away; and -The business office manager said their rule was to get the POC out in 24 hours.

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 policy review, record review and interview the agency failed to ensure staff coordinated care in one (Record/Patient #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Continuity and Coordination of Care," dated 04/2018, showed in part: -The agency coordinates patient care and services to ensure appropriate continuity of care and services from admission through discharge; -Interactive communication between and among home care staff related to specific patients is conducted in such a manner as to provide accurate information about the patient's care, treatment and services, current condition, and any recent or anticipated changes; -The case manager will be responsible for identifying patient care and service needs through the assessment process with collaboration from the patient, caregiver, physician and other home care staff; -Communicating with all staff involved in the patient's care including the physician; -The agency will maintain written documentation of care coordination. The case manager and other disciplines involved in the patient's care communicate regarding care planning and goal setting and participate in case conferences; -Methods utilized to insure the accuracy of information that is communicated between and among home care staff regarding a patient's current condition, plan of care, and progress toward goals include informal, interactive one on one verbal communication, vital sign, wound care and education sheets, patient specific electronic medical record and case conferences; -Patient charts are readily available for review by all home care staff; and -All home care staff are encouraged to review relevant patient data, to verify any received information, and to ask questions related to information or instructions received. RECORD/PATIENT #5: Review of a faxed referral form (undated) from the patient's skilled nursing facility showed: -The patient was to discharge to home on 04/30/2021; -An order for calcium alginate (maintains a moist wound environment to promote healing), gauze sponges and cover with bordered gauze island dressing to the left lateral thigh one time a day; -Apply Santyl (removes dead tissue to promote healing), Xeroform gauze (non-adherent dressing), gauze sponges, secure in place with gauze roll to the left ankle one time a day; -Pressure wound left buttock. After cleansing with normal saline/wound cleanser apply Xeroform gauze, gauze sponges and bordered island gauze one time a day; -Sacrum wound apply Dakins (antimicrobial solution) soaked gauze sponges and cover with bordered gauze island two times a day; -Medihoney (antimicrobial) wound dressing paste to right hip (frequency not documented); and -Maintain #20 (size of catheter) coude catheter (has a bent tip to help get around any blockages). Change every month and as needed. The order did not include what size balloon to use. Review of an agency patient information form showed: -04/30/2021, the patient does not have a physician; -05/03/2021, names a physician who could not take the patient; -05/05/2021, the visiting physician association will have a physician see the patient; and -05/10/10, the visiting physician will sign for the patient. Review of the comprehensive assessment dated 05/11/2021 showed the patient had a urinary catheter 16 french (size of catheter) 10 cc (a balloon at the end of the catheter is filled to hold it in place). Review of the plan of care (POC) dated 05/11/2021 showed: -Diagnoses that included paraplegia (paralysis of the legs), stage 3 (full thickness skin loss) pressure ulcer of the sacral region, left hip, right hip and stage 2 (partial thickness skin loss) pressure ulcer of the left ankle and other site; -SN three times a week to assess pressure injury stage 3 wound to sacrum (close to the tailbone) every visit until healed. SN to perform wound care using aseptic technique, cleanse with Dakins ¼ strength and gauze and cover with ¼ Dakins soaked gauze; -SN to assess and perform wound care to pressure injury stage 3 to the left hip every visit. SN to cleanse with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate, cover with gauze, ABD (large, absorbent) pad and secure with tape; -SN to assess and perform wound care to pressure injury stage 3 to the right hip. SN to cleanse with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate, cover with gauze, ABD pad and secure with tape; -SN to assess and perform wound care to pressure injury stage 2 to the left lateral (side) ankle every visit. SN to cleanse with wound cleanser and gauze, cover with optifoam (foam dressing) 4 x 4 dressing twice a week; -SN to assess and perform wound care to pressure injury stage 2 to the right medial knee. SN to cleanse with wound cleanser and gauze, cover with optifoam 4 x 4 dressing twice a week; and -No orders related to the urinary catheter. Review of the SN visits showed: -On 05/12/2021 the SN performed wound care and instructed the caregiver on wound care, proper turning and repositioning, and skin assessment on bony prominences; -On 05/14/2021 wound care provided per order. Renee (unsure if this meant right knee) cleansed with wound cleanser, applied Xeroform with border gauze, left thigh cleansed with wound cleanser, apply alginate, cover with dressing , L (unsure of what location this was) cleanse with wound cleanser, apply Santyl/Xeroform and cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with a dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant), no dank (unsure if this meant Dakins) in home as on admission orders. (These orders were different from the POC orders and the POC orders did not include an order for the left thigh) Call placed to the physician's office for clarification. SN performed wound care per orders in admission/transfer notes. No documentation was found in the clinical record that the RN case manager was notified regarding the wound care orders; -On 05/17/2021 wound care per order. Renee (unsure if this meant right knee) cleansed with wound cleanser,applied Xeroform with border gauze, left thigh cleansed with wound cleanser, apply alginate, cover with dressing, L (unsure of what this meant) cleanse with wound cleanser, apply Santyl/Xeroform and cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with a dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant), no dank (unsure if this meant Dakins) in home as on admission orders. Call placed to the physician's office for clarification. Spoke with the physician's patient care coordinator, clarified wound care orders, verbally reviewed orders for wound care that is attached from the skilled nursing facility. The patient care coordinator stated to continue the wound care orders, and he/she is ordering the Santyl and Dakins to be delivered to the patient. The physician's office was also looking into a wound care consult for the patient. Wound care performed per orders. The GU section showed Foley catheter change 05/17/2021 with a 20 French, 10 cc catheter. Foley catheter changed via sterile technique 20 french cause (unsure if this meant coude) with yellow urine return. SN provided teaching to caregiver regarding turning and repositioning, attempted teaching on wound care but was busy. Instructed on the use of Dawkins (unsure if this meant Dakins), reviewed orders as to what to do for each wound. No documentation was found in the clinical record that showed the above was discussed with RN A; -On 05/19/2021 wound care per order. Renee (unsure if this meant right knee) cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure what location this was) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant) applied, no dank is in home on admit orders. Call to physician's office for clarification. SN performed wound care as ordered. SN continued teaching positioning in bed, use of pillows to relieve pressure off bony prominences; -On 05/21/2021 wound care per order. Renee (unsure if this meant right knee) cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure of what location this was) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog applied, no dank (unsure if this meant Dakins) is in home on admit orders. Call to physician's office for clarification. SN performed wound care as ordered. Wounds appear cleaner, scant drainage, no odor, appearance improving. Urine cloudy with noted sediment. SN placed tubing correctly to drain to gravity, provided patient education on tubing placement. SN educated on proper fluids to consume. Patient states he/she drinks a lot of caffeinated beverages. SN educated on effects of too much caffeine and encouraged patient to increase water intake. Spoke to the caregiver over the phone, educated on signs and symptoms of urinary tract infection, increase patient intake of proper fluids, report any changed urine appearance, odor, elevated temperature and change in mental status. No documentation of discussion with RN A; -On 05/24/ 2021 wound care per order. Renee (unsure if this meant right knee) cleanse with wound cleanser, apply Xeroform with border gauze. L thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure what location this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, L buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant) applied, no dank (unsure if this meant Dakins) is in home on admit orders. Call to physician's office for clarification. Conferenced with the physician's patient care coordinator and obtained an order to irrigate the catheter (this order was not found in the medical record).The SN assessed 600 milliliters (ml) of yellow urine in the closed drainage bag. The patient's incontinent brief was damp. The caregiver reported by phone the incontinent brief was very wet that morning. The catheter tubing was noted to be upward and over the top of the patient's brief and over the top of the right lower extremity with the patient laying on his/her left side. The SN irrigated the catheter with 60 cc (cubic centimeters) of normal saline per physician order without difficulty. The SN educated the patient on proper positioning of the tubing an upon change of position the need to move the tube with the drainage bag to the other side of the bed. The patient was very reluctant to accept the instruction. The SN educated the patient on the action of draining urine and the patient verbalized he/she will attempt compliance; -On 05/25/2021 wound care per order: cleanse with wound cleanser, apply Xeroform, cover with border gauze (unsure what location this was), Left thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure what location this meant) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant) applied no dank (unsure if this meant Dakins) is in home on admit orders. Call to MD office for clarification. Received a call from the occupational therapy assistant (OTA) of need to assess catheter. Upon arrival, assessment revealed 75 ml in closed drainage bag. Patient laying on five saturated disposal pads. The catheter was coiled inside the incontinent brief with dried bowel movement in the brief. The SN cleansed the patient and provide clean padding and brief. The SN placed the catheter position and noted urine draining. The patient requested the catheter be changed as he/she is convinced that the catheter is not working. The SN changed the catheter via sterile technique with 150 ml of clear, yellow urine return. The SN performed wound care, continued teaching on proper placement of tubing and closed drainage bag. The patient is in the home from early morning to later in the PM as the caregiver works. The caregiver states he/she is in the process of possibly getting private duty through the veterans administration. The SN attempted education to caregiver on proper catheter care, but was unable to participate due to being busy;. No documentation found in the clinical record that the above was discussed with RN A; and -On 05/28/2021 wound care per order: cleanse with wound cleanser, apply Xeroform, cover with border gauze (did not say what location this was), Left thigh cleanse with wound cleanser, apply alginate, cover with dressing. L (unsure what location this was) cleanse with wound cleanser, apply Santyl/Xeroform, cover with dry dressing, left buttock cleanse with wound cleanser, apply Xeroform, cover with dry dressing, sacrum cleansed with wound cleanser, dog (unsure what this meant) applied no dank (unsure if this meant Dakins) is in home on admit orders. Call to physician office for clarification. SN performed wound care as ordered. Upon arrival SN assessed catheter function and placement. The patient continues to keep the catheter tubing upwards and over the top of the lower extremity. The patient declined teaching on proper catheter care. SN educated the patient on catheter drainage to gravity and that catheter changes weekly are not healthy. The patient verbalized understanding. SN attempted teaching on repositioning self every two hours to relieve pressure and patient declined. The SN educated the patient regarding communication with the OT in regards to pressure on feet and pressure points. The OT requested a wedge and heel protectors. The patient stated he/she will not use heel protectors and will consider using the wedge. The patient is alone nine to ten hours daily. The caregiver leaves some food items and fluids on the bedside table, and the patient uses the trapeze to move him/herself in bed but primarily remains on the right side per choice. During an interview on 06/09/2021 at 10:10 AM, RN A stated that: -He/she believed he/she used the wound care orders from the skilled facility; -He/she would call the physician to obtain catheter orders; -He/she added the catheter orders two days ago after the coder told him/her the orders were not on the POC; -He/she would expect an order to be written for the 20/10 cc coude catheter; -He/she gets emails from the LPNs all the time; and -He/she recalled the patient's catheter leaking. During an interview on 06/09/2021 at 12:58 PM, the licensed practical nurse (LPN) C stated that: -He/she did wound care and changed the patient's catheter twice and provided teaching; -The POC orders were not in the system in the beginning; -There was a wound care worksheet, but it had not been completed; -He/she called the physician's office for orders and went step by step with what the physician ordered; -He/she changed the catheter on 05/17/2021. The orders were in an attachment. The clinical manager had showed him/her how to look at the orders in the attachment from the skilled facility; -He/she talked with the RN and clinical manager all the time; and -He/she had talked with the physician's patient care coordinator about the catheter leaking. He/she said to irrigate and change the catheter again. He/she found the order in an attachment from the skilled nursing facility the patient was transferred from. The physician went along with what was in the orders from the facility. He/she did not have any trouble when changing the catheter. The clinical manager ordered the catheters for the patient.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the skilled nurse (SN) provided ongoing assessments in, but not limited to, one (Record/Patient #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #5: Review of the comprehensive assessment dated 05/11/2021 showed: -Three stage 3 (full thickness skin loss) and two stage 2 (partial thickness skin loss) pressure ulcers; and -Patient required a urinary catheter (a tube inserted into the bladder to drain urine). Review of the plan of care (POC) dated 05/11/2021 showed: -Diagnoses that included paraplegia (paralysis of the legs), stage 3 pressure ulcer of the sacral region, left hip, right hip and stage 2 pressure ulcer of the left ankle and other site; -SN three times a week to assess pressure injury stage 3 wound to sacrum (close to the tailbone) every visit until healed. SN to perform wound care using aseptic technique, cleanse with Dakins (antimicrobial cleanser) ¼ strength and gauze and cover with ¼ strength Dakins soaked gauze; -SN to assess and perform wound care to pressure injury stage 3 to the left hip every visit. SN to cleanse with wound cleanser and gauze, apply Santyl (helps to remove dead tissue to aid in wound healing) to wound bed followed by calcium alginate (maintains a moist wound environment to promote healing), cover with gauze, ABD pad and secure with tape; -SN to assess and perform wound care to pressure injury stage 3 to the right hip. SN to cleanse with wound cleanser and gauze, apply Santyl to wound bed followed by calcium alginate, cover with gauze, ABD pad and secure with tape; -SN to assess and perform wound care to pressure injury stage 2 to the left lateral (side) ankle every visit. SN to cleanse with wound cleanser and gauze, cover with optifoam (foam dressing) 4 x 4 dressing twice a week; -SN to assess and perform wound care to pressure injury stage 2 to the right medial knee. SN to cleanse with wound cleanser and gauze, cover with optifoam 4 x 4 dressing twice a wee; and -No orders related to the urinary catheter. Review of the SN visits showed: -From 05/12/2021 through 05/19/2021 no documented wound assessments or measurements; -On 05/21/2021 the wounds appeared cleaner, scant drainage, no odor, appearance improving; -From 05/24/2021 through 05/28/2021 no documented wound assessments or measurements; and -On 05/12/2021, 05/14/2021, and 05/19/2021 under the section for genitourinary (GU) (refers to the genital/urinary system) assessment, the nurse failed to document whether the assessment was within normal limits or characteristics of the urine. During an interview on 06/09/2021 at 10:10 AM, RN A stated that wounds should be assessed at every visit and measured at least once a week. The GU assessment should include color of urine, sediment in the urine, drainage at the insertion site, and catheter care if performed. During an interview on 06/09/2021 at 12:58 PM, LPN C stated that he/she documents weekly measurements and a wound assessment every visit. During an interview on 06/09/2021 at 1:40 PM, the administrator stated that: -The nurse should document a wound assessment at every visit; -The assessment should include what the wound looks like, how deep it is, wound bed, drainage, odor, surrounding skin and wound care provided; -If a patient has a urinary catheter, the nurse should document the color and clarity of urine, whether any signs of infection are present, and education provided; and -He/she did not think staff had been instructed to document narrative notes in their system. During an interview on 06/11/2021 at 10:40 AM, the administrator stated that he/she could not find a policy regarding wound and GU assessments.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with four Conditions of Participation: Patient rights, Care planning, coordination of services and quality of care, Discharge planning and Clinical records, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/14/2023.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body assumes the same responsibilities and obligations as the administrator when the administrator is not available. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: Review of an undated letter provided by the administrator showed: -To whom it may concern; -The administrator has appointed the clinical manager as acting "administer" (supposed to be administrator) in his/her absence effective 03/17/2021; and -The administrator and clinical manager signed the letter. Review of an undated letter provided by the administrator showed: -To whom it may concern; -The administrator has appointed the clinical manager as acting "administer" (supposed to be administrator) in his/her absence effective 06/08/2021; and -The administrator and owner signed the letter. The agency failed to provide documentation from the governing body regarding the appointment of the pre-designated, qualified person to act in the absence of the administrator. During interview on 06/09/2021 at 11:37 AM, the administrator said he/she appointed the administrator designee, not the governing body. The owner was one of two members of the governing body. The administrator and clinical manager were not members of the governing body.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Federal and State law, agency admission packet, home visit observation, and interview, the agency failed to ensure patients and/or representatives were provided written information regarding the Missouri case law "The Cruzan Case" in, but not limited to, three (Record/Patients #1, #2 and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Per 42 CFR 489.102(a)(1)(i) the agency failed to "Provide written information to such individuals concerning - (i) An individuals rights under State law (whether statutory or recognized by courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives." The agency failed to provide the patient with information regarding applicable Missouri case law as set forth in Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990). This case identified that advance directives that do not meet the formal requirements of either a living will or durable power of attorney for health care can be established by "clear and convincing evidence" of the patient's wishes as to the withdrawal of life-sustaining treatment. Review of the agency's admission packet on 6/8/2021 failed to contain information regarding applicable Missouri case law as set forth in Cruzan v. Director, Mo. Dept. of Health. RECORD/PATIENT #1: Observation and interview during the patient's home visit on 06/08/2021 beginning at 11:10 AM, showed the patient's admission packet from the agency failed to include information regarding the Missouri state law "The Cruzan Case." The registered nurse (RN) stated that he/she did not recall that information being in the admission packet. RECORD/PATIENT #2 Observation and interview during the patient's home visit on 06/08/2021 beginning at 10:30 AM, showed the patient's admission packet from the agency failed to include information regarding the Missouri state law "The Cruzan Case." The registered nurse (RN) stated that he/she did not recall that information being in the admission packet. RECORD/PATIENT #3 Observation and interview during the patient's home visit on 06/08/2021 beginning at 1:00 PM, showed the patient's admission packet from the agency failed to include information regarding the Missouri state law "The Cruzan Case." The registered nurse (RN) stated that he/she did not recall that information being in the admission packet. The findings were reviewed with the administrator on 06/09/2021 at 1:55 PM. No further information was provided.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and interview, the agency failed to: - Ensure a complete 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 home health agency within 5 business days of the patient's discharge (G1022); - Ensure clinical record entries are legible, clear, complete, and appropriately authenticated, dated, and timed (G1024); and -Ensure a patient's clinical record must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first) (G1030). The cumulative effects of these deficient practices has the potential to effect all patients served by the home health agency.

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 policy review, record review and interview the agency failed to ensure a complete, comprehensive discharge summary containing relevant information was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's discharge for two (Record/Patient #5 and #6) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Discharge Planning and Discharge," dated 04/2018, showed in part: -The case manager will complete a discharge summary and send a copy of the summary to the physician upon request (the policy failed to address the regulatory requirement that the discharge summary be sent to the physician within five business days, which went into effect 01/13/2018); and -In addition to the discharge OASIS (outcome assessment and information set, a federally mandated assessment) form, a discharge summary will be completed within 48 hours of receiving notice of the discharge. Review of the Condition of Participation: Clinical Records 484.110 Interpretive Guidelines states: - Typically contains the following items: Admission and discharge dates, physician responsible for the home health plan of care (POC), reason for admission to home health, type of services provided and frequency of services, laboratory data, medications the patient is on at time of discharge, patient's discharge condition, patient outcomes in meeting the goals in the POC, and patient and family post-discharge instructions. RECORD/PATIENT #5: Review of a discharge summary dated 06/01/2021 completed by the occupational therapist (OT) showed: -Date completed and discharge date 06/01/2021; -Reason for discharge was non-visit OASIS discharge from agency per the agency's request; -Care summary showed evaluation, standardized testing, bilateral upper extremity strengthening, functional mobility training, optimal positioning, patient and caregiver education; -Current status was blank; -Goals summary/outcomes showed non visit discharge per agency request; -Physician notified of discharge prior to discharge date, per agency policy and timeline; -Discharge from home health services; and -Physician notified of discharge summary availability. The discharge summary failed to contain relevant information such as patient's current status on discharge, the patient's outcomes in meeting his/her goals, and the patient's medications at the time of discharge. During an interview on 06/09/2021 at 10:10 AM, registered nurse (RN) A stated that: -He/she had not finished the OASIS discharge. The discharge was on 06/01/2021; and -A discharge summary is always sent to the physician. He/she did not know of a timeframe to send the summary to the physician. During an interview on 06/09/2021 at 6:30 PM, the OT stated that he/she sent the discharge summary to the personnel in the home health agency office and believed it alerts the agency to send the summary to the physician. During an interview on 06/10/2021 at 10:30 AM, the physician's patient care coordinator stated that: -The RN from the agency notified them of the patient's discharge on 06/01/2021; and -They did not have a discharge summary from the agency. During an interview on 06/11/2021 at 10:45 AM, the administrator stated that the nurse should get a discharge order from the physician, complete the discharge OASIS and send the discharge summary to the physician within five business days. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to the agency on 11/16/2020 with diagnosis of lymphedema (build-up of lymph fluid in the fatty tissues just under your skin). Review of the clinical record showed SN discharged the patient from service on 04/12/2021. The record showed the discharge summary was not completed until 04/28/2021 (16 days after the agency discharged the patient from service). The computer showed the discharge summary was sent 04/28/2021 (16 days after the patient discharged) and the discharge summary failed to include a list of the medications the patient was taking at the time of discharge. During an interview on 06/09/2021 at 12:40 PM the office manager stated he/she gets alerted on the computer when a discharge summary has been completed and ready to send to the primary care practitioner or other health care professional who will be responsible for providing care after discharge and that the medication list was not included in the discharge summary sent to the physician.

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 clinical record review, and interview, the agency failed to ensure all documented entries included appropriate authentication that included the correct date and time the plan of care was completed in, but not limited to, three (Records/Patients #2, #3 and #4) of five full records reviewed and three (Records/Patients #27, #28 and #29) additional records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the policy titled "Clinical Records", dated 03/2018, showed in part the following: -A clinical record containing pertinent past and current findings in accordance with professional standards is maintained for every patient receiving home care services; -The clinical record is reviewed periodically by qualified individuals to determine completeness, accuracy, timely completion of information, and compliance with agency policies; and -Additional information contained in the record will include, but not limited to, the following: *Comprehensive Assessment (including from most recent home health admission, clinical notes, plan of care and physician orders); and *Current Plan of care: including goals and progress toward achieving them. Review of the policy titled "Documentation Policy", dated 03/2018, showed in part the following: -Purpose: To ensure timeliness and accuracy of the information provided; -The care that is provided to each patient is documented in the appropriate visit record (EHR or paper); and -All documentation should be submitted within 48 hours. RECORD/PATIENT #2: Record review showed: -Start of care (SOC) 05/25/2021; -Diagnoses included traumatic hemorrhage of cerebrum, falls, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), athrosclerotic heart disease and hypertension. There was no written POC as of 06/07/2021, 13 days after the SOC. During an interview on 06/07/2021 at 4:44 PM, the office manager stated there was no POC for patient #2. During an interview on 06/08/2021 at 9:00 AM, the office manager stated RN A had completed the POC last night. The POC was provided and dated 05/25/2021 through 07/23/2021. During an interview on 06/09/2021 at 10:54 AM, RN A stated the following: -He/she did not complete Patient #2's comprehensive assessment until he/she was asked to finish on 06/07/2021; and -He/she dated the comprehensive assessment and POC 05/25/2021 instead of 06/07/2021 (date completed) because he/she thought all of the dates should match. RECORD/PATIENT #3: Record review showed: -Start of care (SOC) 05/18/2021; -Diagnoses included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) with diabetic chronic kidney disease, carcinoma (cancer) in prostate, post-traumatic stress disorder, history of falling and long term use of insulin. There was no written plan of care (POC) as of 06/07/2021, 20 days after the SOC. During an interview on 06/07/2021 at 4:44 PM, the office manager stated there was no POC for patient #3. During an interview on 06/08/2021 at 9:00 AM, the office manager stated registered nurse (RN) A had completed the POC last night (06/07/2021). The POC was provided and dated 05/18/2021 through 07/16/2021. During an interview on 06/09/2021 at 9:20 PM, RN A stated the following: -He/she did not complete Patient #3's comprehensive assessment until he/she was asked to finish on 06/07/2021; and -He/she dated the comprehensive assessment and POC 05/18/2021 instead of 06/07/2021 (date completed) because he/she thought all of the dates should match. Record/Patient #4 Record review showed: -Start of care (SOC) was 04/20/2021; -Admitting diagnosis was pressure ulcer of sacral region, stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.); -Plan of care (POC) was dated 04/20/2021 with a typed date; -Review of the episode manager (part of the EHR - electronic health record -software) for nursing showed skilled nursing visits completed on 04/22/2021, 04/24/2021, 04/26/2021, 04/29/2021, 05/03/2021, 05/06/2021, 05/10/2021 and 05/13/2021; -Review of the task details (part of the EHR- electronic health record- software) for the plan of care showed it was created 05/04/2021 (contradicts the typed date of 04/20/2021) , sent to the physician 5/13/2021 and returned with the physician signature 05/14/2021; and -Staff provided care to the patient prior to the plan of care being created for a total of 14 days. Record/Patient #27 Record review showed: -Start of care (SOC) was 05/06/2021; -Admitting diagnosis was pressure ulcer of right buttock, stage 3 (Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.); -Plan of care (POC) was dated 05/06/2021 with a typed date; -Review of the episode manager for nursing showed skilled nursing visit completed on 05/10/2021; -Review of the task details for the plan of care showed it was created. 06/03/2021 (contradicts the typed date of 05/06/2021) , sent to the physician 06/07/2021(the day the state surveyors entered the agency for survey) and returned with the physician signature 06/07/2021; and -Staff provided care to the patient prior to the plan of care being created for a total of 19 days. Record/Patient #28 Record review showed: -Start of care (SOC) was 04/20/2021; -Admitting diagnosis was pressure ulcer of sacral region, stage 4; -Plan of care (POC) was dated 4/20/2021 with a typed date; -Review of the episode manager for nursing showed skilled nursing visits completed on 4/23/2021, 4/27/2021, 4/29/2021, 5/04/2021 and 5/06/2021; -Review of the task details for the plan of care showed it was created 05/04/2021 (contradicts the typed date of 04/20/2021), sent to the physician 05/06/2021 and 05/19/2021 and returned with the physician signature 05/26/2021; and -Staff provided care to the patient prior to the plan of care being created for a total of 14 days. Record/Patient #29 Record review showed: -Start of care (SOC) was 04/23/2021; -Admitting diagnosis was infection and inflammatory reaction due to indwelling urethral catheter; -Plan of care was dated 04/23/2021 with a typed date; -Review of the episode manager for nursing showed skilled nursing visits completed on 04/27/2021, 04/29/2021, 05/04/2021, 05/06/2021 and 05/12/2021; -Review of the task details for the plan of care showed it was created 05/12/2021 (contradicts the typed date of 04/23/2021), sent to the physician 05/13/2021 and returned with the physician signature 05/17/2021; and -Staff provided care to the patient prior to the plan of care being created for a total of 19 days. During an interview on 06/09/2021 at 2:25 PM, the administrator said he/she expected the nurse to date the actual date the assessment/plan of care was completed. The nurses should not back date their assessments or plan of care. During an interview on 06/10/2021 at 3:00 PM, IT senior technical support analyst stated the work log shows when the task was created in the software and the date cannot be changed on the work log but the date can be changed to what the staff want it to show signed. Staff can also unlock and backdate the forms. During an interview on 06/11/2021 at 11:56 AM, the administrator stated staff were not getting a verbal or signed order until the plan of care was created. Staff were completing visits with patients from the start of care and prior to the plan of care being completed and signed. Staff were doing hands on care including catheter care, diabetic blood sugar care and other orders including wound treatments.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on review of the home packet information provided to the patients, review of Covid-19 Emergency Declaration Blanket Waivers, and staff interview, the agency failed to ensure accurate information provided to the patients regarding the retrieval of clinical records, specifically that the clinical record must be made available to the patient, free of charge, and upon request at the next home visit or within four business days (whichever comes first). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's home packet information section titled "Notice of Privacy Practices," under heading "Your Rights" provided to the patients at the start of care, showed: - The patient had a right to get an electronic or paper copy of his/her medical record; - A copy or a summary of the health information would be provided, usually within 30 days of the request; and - May charge a reasonable, cost-based fee. Review of the Covid-19 Emergency Declaration Blanket Waivers for Health Care Providers, last updated 05/24/2021 showed in part: - In accordance with section 1135(b)(5) of the Act, CMS is extending the deadline for completion of the requirement at 42 CFR §484.110(e), which requires HHAs to provide a patient a copy of their medical record at no cost during the next visit or within four business days (when requested by the patient). Specifically, CMS will allow HHAs ten business days to provide a patient ' s clinical record, instead of four. RECORD/PATIENT #1: During a home visit observation on 06/08/2021 beginning at 11:10 AM, review of the admission packet information for Patient #1 showed the patient had the right to get an electronic or paper copy of his/her medical record and a copy or a summary of the health information would be provided, usually within 30 days of the request and the agency may charge a reasonable, cost-based fee. RECORD/PATIENT #2: During a home visit observation on 06/08/2021 at 10:30 AM, review of the admission packet information for Patient #2 showed the patient had the right to get an electronic or paper copy of his/her medical record and a copy or a summary of the health information would be provided, usually within 30 days of the request and the agency may charge a reasonable, cost-based fee. RECORD/PATIENT #3: During a home visit observation on 06/08/2021 at 1:00 PM, review of the admission packet information for Patient #3 showed the patient had the right to get an electronic or paper copy of his/her medical record and a copy or a summary of the health information would be provided, usually within 30 days of the request and the agency may charge a reasonable, cost-based fee. The agency failed to provide the patients with accurate information that his/her medical record must be made available free of charge (not for a cost-based fee) and within four business days (currently 10 business days due to the federal waiver) (not 30 within 30 days). During an interview on 01/09/21 at 10:30 AM, the administrator stated that is what is given to the patients on admission and he/she was planning to review and update the information in the admission booklet.