Every finding on record at Medistar Home Health of Baton Rouge, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: ADL- Activities of Daily Living CBC- Complete Blood Count mmol/L - Millimoles per liter OASIS- Outcome and Assessment Information Set RN- Registered Nurse

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Review of the agency’s policy titled, “Encoding and Reporting Oasis Data” dated 09/09/2020 revealed the following, in part: Policy Overview: The agency will electronically report all OASIS data collected in accordance with federal regulations. Procedure: 1. The agency will submit individual client assessment data within 30 days of completing the comprehensive assessment. This will be done within 30 days of the day the OASIS was completed. Review of the agency’s OASIS Final Validation Report with a submission date of 06/07/2024 revealed 9 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 06/11/2024 revealed 12 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 06/27/2024 revealed 5 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Final Validation Report with a submission date of 08/28/2024 revealed 11 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S1ADM on 11/13/2024 at 3:00 p.m. She reviewed the agency’s OASIS validation reports and verified the above records were submitted late. She confirmed the OASIS records should have been submitted within 30 days of completion.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the OASIS data accurately reflected the patient's status at the time of assessment. The agency inaccurately documented a patient’s discharge status for 1 (#12) of 4 (#10, #11, #12, and #13) patient discharge records reviewed. Findings: Review of Patient #12’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/27/2023, had a Certification Period of 07/27/2023 to 09/24/2023 and was discharged from the agency on 09/21/2023. Review of Patient #12’s Coordination Notes dated 09/18/2023 revealed the following, in part: Patient currently at a local hospital Room 4258. Review of the Discharge OASIS dated 09/21/2023 for Patient #12 and completed by S2RN revealed the following, in part: Discharge/Inpatient Admission: To which inpatient facility has the patient been admitted to? NA-No Inpatient Facility Admission Discharge Disposition: Where is the patient after discharge from your agency? 1-Patient remained in the community (without formal assistance services) An interview was conducted with S2RN on 11/13/2024 at 8:40 a.m. She stated Patient #12 was admitted to the hospital at the end of his certification period. She confirmed Patient #12’s Discharge OASIS dated 09/21/2023 was not accurately coded and should have been. An interview was conducted with S1ADM on 11/12/2024 at 2:00 p.m. She reviewed Patient #12’s coordination notes and Discharge OASIS dated 09/21/2023. She confirmed the last coordination note in the clinical record dated 09/18/2023 stated the patient was at the hospital. She confirmed the Discharge OASIS was not accurately coded and should have been.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the RN provided home health agency services in accordance with current clinical practice guidelines and accepted professional standards for 2 (#9 and #12) of 4 (#1, #9, #12 and #13) patients reviewed for pressure ulcers. The agency failed to ensure the RN assessed and staged Patient #9 and #12’s pressure wounds on a weekly basis. Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the agency’s policy titled “Wound Measurement” dated 12/04/2019, revealed the following, in part: Procedures: g. Documentation of wound measurements is a part of the required documentation for all wound care procedures. Review of the agency’s policy titled “Assessment/Staging of Pressure Ulcers” dated 12/04/2019, revealed the following, in part: Pressure Ulcer Assessment Guide 1. In assessing the pressure ulcer, the following parameters should be addressed consistently. Site, stage of ulcer and size of ulcer. ( include length, width and depth) Patient #9 Review of the Clinical Record for Patient #9 revealed she began receiving services from the Home Health Agency on 03/29/2023 and had a current Certification Period of 09/19/2024 to 11/17/2024. Patient #9 had diagnoses, which included Pressure Ulcer of Sacral Region, Stage 3. Review of the current Physician’s Orders for Patient #9 revealed the following, in part: Cleanse the wound with wound cleanser and gauze. Pat dry with gauze, apply moistened collagen to wound bed. Apply 2x2 hydrocolloid with foam boarder dressing to prevent saturation from urine and feces. Change 2 times a week excluding wound care days and prn if soiled or dislodged. Review of the Skilled Nursing Visit notes conducted for Patient #9 for Certification Period 09/19/2024 to 11/17/2024 revealed Patient #9’s Sacral Pressure Ulcer, Stage 3 was not assessed to include measurements of the Pressure Ulcer the weeks of 10/07/2024 and 10/14/2024. Patient #12 Review of the Clinical Record for Patient #12 revealed he began receiving services from the Home Health Agency on 07/27/2023, had a Certification Period of 07/27/2023 to 09/24/2023, and was discharged from the agency on 09/21/2023. Patient #12 had diagnoses, which included Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side. Review of the Skilled Nursing Visit notes conducted for Patient #12 for Certification Period 07/27/2023 to 09/24/2023 revealed Patient #12’s Right Buttock Pressure Ulcer, Stage 2 with an onset date of 09/06/2023 was not assessed to include measurements by an RN the weeks of 09/06/2023 and 09/10/2023. An interview was conducted on 11/13/2024 at 3:00 p.m. with S1ADM. She verified pressure wounds should be assessed and measured by a Registered Nurse at least weekly. She confirmed a Registered Nurse had not assessed or measured Patient #9 and #12’s wounds listed above weekly.

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 record reviews and interview, the agency failed to ensure services ordered by the Physician were provided as indicated in the Plan of Care as evidenced by: 1. Home Health Aide (HHA) visits were not conducted as ordered for 1 (#11) of 4 (#5, #7, #8 and #11) patient records reviewed with orders for Home Health Aide services; and 2. Home Health Therapy visits were not conducted as ordered for 1 (#12) of 9 (#2, #3, #4, #7, #8, #10, #11, #12, and #13) patient records reviewed with orders for Home Health Therapy services. Findings: Patient #11 Review of Patient #11’s Clinical Record revealed she began receiving services from the Home Health Agency on 08/02/2023, had a Certification Period of 08/02/2023 to 09/30/2023, and was discharged from the agency on 09/29/2023. Patient #11 had diagnoses, which included Hypertensive Heart Disease with Heart Failure, Acute on Chronic Diastolic Congestive Heart Failure, Acute Respiratory Failure with Hypoxia, and Unspecified Obesity. Further review revealed a physician’s order dated 08/01/2023 for admit to home health, Aide to provide assistance with personal care, ADLs, and vital signs. Review of Patient #11’s Client Calendar Report revealed no documentation of HHA visits for the Certification Period 08/02/2023 to 09/30/2023. Patient #12 Review of Patient #12’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/27/2023, had a Certification Period of 07/27/2023 to 09/24/2023, and was discharged from the agency on 09/21/2023. Patient #12 had diagnoses, which included Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side and Personal History of Malignant Neoplasm of Large Intestine. Further review revealed a physician’s order dated 07/25/2023 for admit to home health, Home Health Therapy to be continued upon discharge. Review of Patient #12’s Client Calendar Report revealed no documentation of Home Health Therapy visits for the Certification Period 07/27/2023 to 09/24/2023. An interview was conducted with S1ADM on 11/12/2024 at 2:00 p.m. She reviewed Patient #11’s clinical record and physician orders dated 08/01/2023. She confirmed the physician ordered Home Health Aide services. She further confirmed there was no documentation as to why the HHA services were not provided or the physician being notified Aide services were not provided and there should have been. She reviewed Patient #12’s clinical record and physician orders dated 07/25/2023. She confirmed the physician ordered Home Health Therapy services. She further confirmed there was no documentation as to why the Therapy services were not provided or the physician being notified Therapy services were not provided and there should have been.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure a Physician was notified regarding a change in patient's status as evidenced by the agency failing to: 1. Ensure pain was communicated to the Physician for 1 (#10) of 13 (#1-#13) patients record reviewed; and 2. Ensure a low Potassium level was communicated to the Physician for 1 (#12) of 13 (#1-#13) patients records reviewed; Patient #10 Review of Patient #10’s Clinical Record revealed she began receiving services with the agency on 08/13/2024 and had a certification period of 08/13/2024 to 10/11/2024. Patient #10 had diagnoses, which included Interstitial Pulmonary Disease. Further review revealed Patient #10 received Physical Therapy services two times a week for three weeks and one time a week for one week. Review of Patient #10’s Coordination Notes for certification period 08/13/2024 to 10/11/2024 revealed no notification to the Physician of Patient #10’s leg pain. Review of Patient #10’s Physical Therapy Assistant’s notes revealed the following, in part: 09/17/2024 -Patient continues to have leg pain with standing/walking. Signed S3PTA. 09/19/2024-Patient participation in therapy continues to be limited by pain. Patient has not been compliant with home exercise program and spends most of the day in bed due to pain at legs/low back. Signed S3PTA. An interview was conducted on 11/13/2024 at 8:00 a.m. with S3PTA. She said she was unsure if she notified Patient #10’s Physician regarding her continued leg pain. She said if she would have notified the Physician, it would have been documented in Patient #10’s Clinical Record. An interview was conducted on 11/13/2024 at 11:15 a.m. with S1ADM. She reviewed Patient #10’s visit notes dated 09/17/2024 and 09/19/2024 and confirmed S3PTA should have informed Patient #10’s Physician of her pain and decreased participation in physical therapy and did not. Patient #12 Review of Patient #12’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/27/2023, had a Certification Period of 07/27/2023 to 09/24/2023 and was discharged from the agency on 09/21/2023. Patient #12 had diagnoses, which included Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus, Essential Hypertension, and Personal History of Malignant Neoplasm of Large Intestine. Further review revealed Patient #12 received Skilled Nursing Visits once weekly for nine weeks for the Certification period of 07/27/2023 to 09/24/2023. Review of Patient #12’s Plan of Care dated 07/27/2023 revealed the following, in part: Skilled Nurse to obtain blood specimen via venipuncture for labs as ordered CBC, Chem 7 in 1 week. Obtain lab results and report to physician. Review of Patient #12's Laboratory Results dated 08/10/2023 revealed the following, in part: Potassium 3.0 mmol/L Low, Reference Interval (3.5-5.2) Review of Patient #12's Nurses’ Notes dated August 2023 revealed no documented evidence the physician was notified or the agency followed up regarding Patient #12's low Potassium results on 08/10/2023. An interview was conducted with S1ADM on 11/12/2024 at 2:00 p.m. She reviewed Patient #12’s clinical record and laboratory results dated 08/10/2023 and confirmed the patient had a low Potassium level of 3.0. She stated Patient #12’s laboratory results were faxed to the physician on 08/11/2023. She confirmed there was no documentation the agency staff communicated or followed up with Patient #12's physician regarding the Potassium level of 3.0. She stated a patient with a low Potassium level would warrant a follow up phone call from the agency to the physician. She confirmed a Potassium level outside of therapeutic range could have affected Patient #12’s health.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized PoC (plan of care) was followed as evidenced by the SN (skilled nurse) failing to perform and record blood sugar readings as ordered per the PoC for 2 (#1 and #5) out of 7 (#1-7) sampled patients. Patient #1. Patient #1 was admitted to the agency on 1/28/2021, and had diagnoses including Pressure Ulcer of the Sacral Region, Stage 2, Spiral Fracture of Right Tibia, Atherosclerotic Heart Disease, Chronic Kidney Disease, Congestive Heart Failure, and Type 2 Diabetes. The certification period reviewed was from 11/24/2021 to 1/22/2022. Review of the patient's PoC (Plan of Care) revealed an order for skilled nurse effective 11/28/2021 1wk8 (skilled nurse visits once time weekly for times a week for eight weeks). Further review of the patient's POC revealed an order for "Skilled nurse to perform and record blood sugar reading PRN (as needed) for signs and symptoms of hypo/hyperglycemia”. A review of a Nurse Visit Report dated 12/07/2021 conducted by S8RN failed to reveal that the nurse had performed a blood sugar on Patient #1. A Nurse Visit Report dated 12/28/2021 conducted by S7RN failed to reveal that the nurse had performed a blood sugar on Patient #1. A home visit was conducted with Patient #1 and S3RN on 1/04/2022. During the home visit, S3RN failed to perform a blood sugar on Patient #1. The nurse stated that she did not have glucometer strips with her and was not able to conduct the blood sugar on Patient #1. On 1/05/2022 at 1:30 PM, an interview was conducted with S2ADM. She reviewed the orders on Patient #1’s PoC and confirmed the order -Skilled Nurse to perform and record blood sugar reading PRN for signs and symptoms of hypo/hyperglycemia. S2ADM stated that “PRN” was unfortunate for that order and not appropriate. S2ADM stated that the nurses are to conduct blood sugar assessments on all Diabetic patients on each nurse visit. On 1/05/2022 at 12:30 PM, an interview was conducted with S1DON. She reviewed Patient #1’s Visit Note Reports for the current certification period from 11/24/2021 to 1/22/2022. S1DON confirmed that on 12/07/2021, 12/28/2021, and 1/04/2022 the nurses failed to follow the PoC and had not conducted blood sugars on the patient as ordered. Patient #5. Review of the patient's electronic clinical record revealed the start of care date was 8/20/2021. The patient's diagnosis included Type 2 Diabetes Mellitus with Foot Ulcer and with Peripheral Angiopath without Gangrene, and Long Term Use of Insulin. The certification period reviewed was 12/18/2021 to 2/15/2022. Review of the patient's POC for certification period 12/18/2021 to 2/15/2022 revealed an order for skilled nurse effective 12/19/2021 3wk8, 1wk1 (skilled nurse visits three times a week for eight weeks, skilled nurse visit one time a week for one week). Further review of the patient's POC revealed an order for "Skilled nurse to perform and record blood sugar reading daily…" Review of the patient's SN visit notes dated 12/22/2021 and 12/24/2021 revealed that there was no evidence that the patient's blood sugar reading was performed and recorded as ordered. On 1/5/2022 at 12:20 pm, S1DON (Director of Nurses) reviewed the patient’s electronic records and the patient’s skilled nurse notes dated 12/22/2021 and 12/24/2021 and confirmed that there was no evidence that the skilled nurse had performed and recorded the patient’s blood sugar reading for those dates.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care included a sliding scale chart for insulin dosage for 1 (#2) out of 7 sampled patients. Patient #2. Review of the patient's electronic clinical record revealed start of care date 10/19/2021. The patient's diagnoses included Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes with Diabetic Peripheral Angiopath without Gangrene. The certification period reviewed was 12/18/2021 to 2/15/2022. Review of the patient's POC (Plan of Care) for certification period 12/18/2021 to 2/15/2022 revealed an order for SN effective 12/19/2021 1wk4, 1every2wk4 (skilled nurse visit one time a week for four weeks, one visit every two weeks for four weeks). Further review of the POC revealed medication orders for “Novolog mix 70-30 Flexpen U-100 Insulin 100 unit/ml 20 units 3 times daily/prn per sliding scale”. There was no evidence of a written sliding scale chart for insulin dosage noted in the POC. On 1/6/2022 at 1:50 pm, an interview was conducted with S6CL (Community Liaison). S6CL reviewed the patient’s electronic clinical records and confirmed that there was no evidence of a written sliding scale chart for insulin dosage noted in the patient’s record. Also, S6CL stated that the agency did not have standing orders for sliding scale. On 1/6/2022 at 2:10 pm, an interview was conducted with S4RN (Registered Nurse). S4RN stated that on a home visit, she saw the bottle of Novolog insulin in the home and it was labeled 20 units 3 times daily prn per sliding scale. S4RN stated that she did not get an order for a sliding scale and she verified that there was no sliding scale chart for insulin dosage in the patient’s clinical record.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was promptly alerted of vital signs falling out of the established parameters for 2 (#1 and #4) patients out of a total sample of 7 (#1-7) patients. Patient #1. Patient #1 was admitted to the agency on 1/28/2021, and had diagnoses including Pressure Ulcer of the Sacral Region, Stage 2, Spiral Fracture of Right Tibia, Atherosclerotic Heart Disease, Chronic Kidney Disease, Congestive Heart Failure, and Type 2 Diabetes. The certification period reviewed was from 11/24/2021 to 1/22/2022. A review of the PoC (Plan of Care) revealed orders for the Licensed Professional to report vital signs falling outside the following established parameters. The parameters to report for Pulse was less than 60, Respirations greater than 24, and Pain greater than 5. A review of a Nurse Visit Report dated 12/21/2021 was conducted. S7RN had conducted the skilled nurse visit and had documented Patient #1’s Pulse as 58, Respirations as 58, and Pain as 8. A Vital Sign Alert box was noted on the nurse visit report, alerting that the vital signs were out of established parameters. Comments noted in the three alert boxes was “Seeing PCP today, follow up comment entered by S10LPN, Clinical Coordinator on 12/28/2021. Faxed to MD on 12/28/2021”. Further review of the visit report failed to reveal that the patient’s physician had been made aware of the abnormal vital signs. A review of a Nurse Visit Report dated 12/28/2021 was conducted. S7RN had conducted the skilled nurse visit. No evidence that Patient #1’s physician had been made aware of the abnormal vital signs assessed on 12/21/2021 was noted. A review of the agency’s policy titled “Skilled Nursing Services” was conducted. It included in part Procedures: 1. The registered nurse: e. informs the physician or allowed practitioner and other personnel of changes in the client’s needs. On 1/05/2022 at 1:30 PM, an interview was conducted with S2ADM. She reviewed the Nurse Visit Report dated 12/21/2021 and confirmed that Patient #1’s Pulse, Respirations, and Pain was outside of the established parameters on the PoC, and had automatically initiated alerts for the abnormal assessments. She reviewed the comments on the visit report that the patient was seeing the PCP (Primary Care Physician) on 12/21/2021 and that the Clinical Coordinator had entered a follow up comment and faxed the MD (Medical Doctor) on 12/28/2021. She stated that the alerts on the visit note does not indicate that the abnormal vital signs have been automatically sent the physician, the agency staff still have the task to notify them. S2ADM further stated that the policy of the agency is that staff notify a patients’ physician at the time the abnormal vital signs are obtained. On 1/07/2022 at 11:30 AM, an interview was conducted with S1DON. She reviewed the Nurse Visit Report from 12/21/2021 and confirmed that S7RN had assessed Patient #1’s Pulse as 58, Respirations as 58, and Pain as an 8, which created alerts for the nurse, as they were outside of the normal vital sign parameters. She further stated that S7RN should have notified the patient’s physician at that point about the abnormal vital signs and confirmed that there was no evidence that they were reported to the physician until 12/28/2021. Patient #4. Review of the patient's electronic clinical record revealed the start of care date was 12/10/2021. The patient's diagnoses included Fracture of Right Acetabulum, Diabetes, and Hypertension. The certification period reviewed was 12/10/2021 to 2/7/2022. Review of the patient's POC (Plan of Care) for certification period 12/10/2021 to 2/7/2022 revealed an order for SN 1wk9 (skilled nurse visit one time a week for nine weeks), PT effective 12/10/2021 1wk1, 2wk3 (Physical Therapy visits one time a week for one week, two visits a week for three weeks), OT effective 12/12/2021 1wk1, 2wk3 (Occupational Therapy visits one time a week for one week, two visits a week for three weeks), MSW effective 12/19/2021 1wk2 (Medical Social Worker visits one visit a week for 2 weeks). Further review of the patient’s POC revealed an order for “Licensed Professional to report vital signs falling outside the following established parameters:.. Pain >5…”. Review of the patient's PT (Physical Therapist) Visit Note dated 12/10/2021 revealed that under pain assessment, the patient complained of pain of 8 on a scale of 0-10. There was no evidence that the PT reported the pain to the patient’s physician. Review of the patient’s OT (Occupational Therapist) Visit Note dated 12/13/2021 revealed that under pain assessment, the patient complained of pain of 8 on a scale of 0-10. There was no evidence that the OT reported the pain to the patient’s physician. Review of the patient’s MSW (Medical Social Worker) Visit Note dated 12/20/2021 revealed that under pain assessment, the patient complained of pain of 8 on a scale of 0-10. There was no evidence that the MSW reported the pain to the patient’s physician. Review of the patient's PTA (Physical Therapy Assistant) Visit Note dated 12/21/2021 revealed that under pain assessment, the patient complained of pain of 7 on a scale of 0-10. There was no evidence that the PTA reported the pain to the patient’s physician. On 1/4/2022 at 2:50 pm, an interview was conducted with S1DON (Director of Nurses) and after a review of the patient's clinical record, S1DON verified that there was no evidence that the physician was notified of the patient’s complaint of pain on those dates. Also, S1DON stated that the patient’s complaints of pain should have been reported to the physician.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency's staff failed to ensure communication with all physicians involved in the plan of care, by failing to ensure that the physician was made aware of the need for a glucometer and that progress notes/orders had been received from the physician, after patient appointments for 1 (#1) patient, out of a total sample of 7 (#1-7) patients. 1. Patient #1 was admitted to the agency on 1/28/2021, and had diagnoses including Pressure Ulcer of the Sacral Region, Stage 2, Spiral Fracture of Right Tibia, Atherosclerotic Heart Disease, Chronic Kidney Disease, Congestive Heart Failure, and Type 2 Diabetes. The certification period reviewed was from 11/24/2021 to 1/22/2022. A review of the PoC (Plan of Care) revealed orders for: Skilled Nurse to perform and record blood sugar reading PRN (as needed) for signs and symptoms of hypo/hyperglycemia. DME (Durable Medical Equipment) and supplies on the PoC included a glucometer. During a home visit with Patient #1 and S3RN on 1/04/2022 at 1:30 PM, S3RN took the patient’s blood pressure in her right upper arm and the patient reported that her arms hurt “greater than 5 but hard to label. It hurts”. S3RN reported to the surveyor that Patient #1 had received therapy in the past for pain. She asked Patient #1 if she felt that she needed therapy and if her pain was less when she was receiving therapy. The patient responded that she did feel like she needed therapy because her pain was tolerable when she had been receiving therapy. At the completion of the visit, the surveyor questioned S3RN why she had not assessed Patient #1’s blood sugar. S3RN asked the patient if she had a glucometer and the patient stated that she had not had a glucometer to check her blood sugar for quite a long time. S3RN stated that she would notify the physician about the need for a glucometer and for the patient’s complaints of pain. A Review of Patient #1’s electronic record revealed a Nurse Visit Report dated 12/02/2021 conducted by S7RN revealed a random blood sugar of 236. A Nurse Visit Report dated 12/07/2021 conducted by S8RN revealed that a blood sugar was not obtained during the visit. Documentation in the visit included “Pt (patient) does not check bc (because) she doesn’t have glucometer”. Case Coordination on the visit note included: Indicate next MD visit – S9MD_ 12/9/21”. Narrative by S8RN on the visit noted include: She has appointment card with appt for Thursday 12/9/21 @ 1100…. Patient does not have glucometer in home…. Physician update sent to S9MD requesting RX for one….Patient reports that her blood sugar has been elevated during the last few nurse visits. A Nurse Visit Report dated 12/14/2021 conducted by S4RN revealed a fasting blood sugar of 179. Narrative by S4RN included “SN (Skilled Nurse) performed fasting blood sugar”. No evidence that the patient had received a glucometer was found. A Nurse Visit Report dated 12/21/2021 conducted by S7RN revealed a fasting blood sugar of 160. No evidence that the patient had received a glucometer was found. A Nurse Visit Report dated 12/28/2021 conducted by S7RN failed to reveal that a blood sugar had been assessed during the visit. No evidence that Patient #1 had received a glucometer was found. A Nurse Visit Report dated 1/04/2022 conducted by S3RN revealed a pain level of 6/10. Care Coordination on the visit note included “12/9/21 had visit with new Dr. _S9MD_. Will contact him for last Dr. note. Also noted on Visit Note Report under Endocrine/Hematopoietic…..frequency blood sugar checked: only during nursing visits. Did ask Dr. for new glucometer. Narrative documentation made by S3RN revealed the following: Patient stated that her pain was 6 on a scale of 1 to 10….she is always in pain. Pt may benefit from therapy as she doesn’t get out the bed often. Left message with _Dr. _S9MD_ regarding pain…. She no longer has a glucometer. Dr. was messaged in December about getting a new glucometer because some of the recent nurses have checked her CBGs and it was high. I’ll send the Dr. another note in regards to this. Left message with Dr._S9MD_ regarding glucometer….pain…..Patient states that she has an appointment with you on December 9, 2021. Can we please get a copy of the latest note… Further review of Patient #1’s electronic record failed to reveal that the physician had responded to the update sent on 12/07/2021 requesting a glucometer for the patient, nor had the agency attempted additional communication regarding a glucometer since the initial request. Continued review of the electronic record failed to reveal that the agency had received documentation or orders from Patient #1’s appointment on 12/09/2021 from S9MD. A review of the agency’s policy titled “Skilled Nursing Services” was conducted. It included in part Procedures: 1. The registered nurse: e. informs the physician or allowed practitioner and other personnel of changes in the client’s needs. On 1/05/2022 at 12:30 PM, an interview was conducted with S1DON. She stated that the nurses carry glucometers with them to conduct blood sugars if a patient does not have a glucometer. On 1/05/2022 at 1:30 PM, an interview was conducted with S2ADM. She reviewed the orders on Patient #1’s PoC and confirmed the order -Skilled Nurse to perform and record blood sugar reading PRN for signs and symptoms of hypo/hyperglycemia. S2ADM stated that “PRN’ was unfortunate for that order, as it was not appropriate, and stated that the nurses are to conduct blood sugars on all Diabetic patients on each nurse visit. She confirmed that on 12/07/2021 the nurse had documented that the resident did not have a glucometer and an attempt to obtain one from the physician was documented. She reviewed the patient’s record and confirmed that there was no evidence that the agency had followed up with the physician to ensure he had received the request for the glucometer or to obtain the device for the patient after 12/07/2021. On 1/07/2022 at 11:30 AM, S1DON confirmed that the agency had failed to obtain the physician’s progress notes and/or orders from Patient #1’s visit with S9MD on 12/09/2021. At that time, S1DON conducted a telephone conversation with S9MD’s office staff. She was notified that there was no appointment on 12/09/2021 that the patient had seen S9MD on 12/21/2021, and an X-Ray had been done on that day for shoulder pain. At that time a fax was received from S9MD’s office with the results of the X-Ray, which revealed Left Shoulder Pain, Severe Acromioclavicular and Glenohumeral DJD (Degenerative Joint Disease), and Osteopenia. S1DON presented Client Coordination Note Reports and orders for the current certification period for Patient #1. A review of the documents was conducted along with S1DON. A Client Coordination Note Report dated 01/05/2022 entered by S3RN included the following: Follow Up call with S9MD office. Spoke with (office staff) regarding….getting glucometer due to high blood glucose levels during the past month so that way we are better able to take care of her….getting the patient physical therapy and/or putting her back on tramadol due to her pain still being high in her bilateral upper extremities….asked for a visit summary for last visit on 12/9/2021...; and A voice order received from S9MD on 1/6/2022, taken by S3RN included the following: Physical Therapy ordered due to arthritis and pain 6 on a pain scale of 1 to 10 in shoulders per S9MD (XRAYS done on 12/9 in office showed the arthritis) and Glucometer called in to _pharmacy name_ for daily CBG testing; and A note dated 01/06/2022 entered by S3RN included: Spoke to S9MD. I explained that her (patient #1) CBG has been between 160 and 236 so we are ordering a glucometer for her at (pharmacy name). Physical Therapy was also ordered because doctor stated at last doctor’s visit on December 9th patient had an X-Ray that showed arthritis in her shoulders and try to call her office for therapy orders but was not sure of the company she was with. During the document review, S1DON stated that she could not explain the contents of the note dated 1/06/2022. At 1:53 PM, S1DON called S3RN, and a telephone interview was conducted at that time with both staff. S3RN stated that she spoke to S9MD on 1/06/2022 to obtain the progress notes and any orders from Patient #1’s visit on 12/09/2021. She stated that S9MD informed her that an X-Ray done on 12/09/2021 revealed arthritis to the patient’s arm, which had been causing her pain. S9MD informed S3RN that he did not know which home health agency Patient #1 was receiving services from, and did not know who to call to order therapy for the patient’s pain. S1DON confirmed that the agency documentation revealed that they were aware that Patient #1 had an appointment scheduled with S9MD on 12/09/2021 and had failed ensure that they received communication from the physician regarding that appointment. She confirmed that the agency was not aware that the patient saw S9MD on 12/21/2021 and that he wanted to order therapy based on the X-Ray results and complaints of pain. S1DON further confirmed that the agency failed to ensure that the communication sent to the physician on 12/7/2021 regarding the patients’ need for a glucometer had been received. S1DON confirmed that as of now, there was no glucometer in the home.

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 record review and interview, the agency failed to ensure entries were appropriately dated and timed, as evidenced by the nurse failing to complete documentation of skilled nurse visits on the Visit Note Reports within 48 hours of conducting the visit for one patient (#1) as per the agencies policy and protocol, out of a total of 7 (#1-7) sampled patients. Patient #1 was admitted to the agency on 1/28/2021, and had diagnoses including Pressure Ulcer of the Sacral Region, Stage 2, Spiral Fracture of Right Tibia, Atherosclerotic Heart Disease, Chronic Kidney Disease, Congestive Heart Failure, and Type 2 Diabetes. The certification period reviewed was from 11/24/2021 to 1/22/2022. A review of a Visit Note Reports for Patient #1 revealed that S7RN had conducted a visit on 12/01/2021. Further review of the note revealed that the nurse had not signed it until 12/10/2021. Further review revealed that S7RN had conducted a visit on 12/21/2021 and had not signed it until 12/28/2021. On 1/7/2021 at 10:00 AM, an interview was conducted with S1DON. She reviewed the Visit Note Reports for Patient #1. She confirmed that S7RN had conducted the patient’s nurse visits on 12/01/2021 and 12/21/2021, and had failed to sign and date the documents within 48 hours, which was the policy of the agency. On 1/7/2021 at 10:20 AM, S2ADM presented a policy titled “Clinical Documentation and Changes to the Medical Record”. Procedure #4 included “Documentation shall be completed as soon as possible to meet the clinical and operations standards, but no later than the state defined timeframe”. She stated that the agency’s policy was that the nurse was to complete the visit documentation, including signing and dating the visit note, within 48 hours of the completion of the visit. She confirmed that S7RN had failed to follow this policy on 12/02/2021 and 12/10/2021.