Every finding on record at Mount Evans Hospice Inc

A recertification survey was completed on 10/10/24. One deficiency was cited.

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 observations and interviews, the agency failed to ensure that staff provided care in accordance with current clinical practice guidelines and accepted professional standards of practice in 2 of 2 patients, who received peripherally inserted central catheter (PICC) line treatment, reviewed (Patients #1 and #2). Findings include: 1. The clinical record for Patient #1 was reviewed on 10/8/24. Review of the plan of care for the certification period of 8/30/24 to 10/28/24 revealed a start of care date of 8/30/024. Relevant diagnosis include encounter for adjustment and management of vascular access device, infection and inflammatory reaction due to other cardiac and vascular devices ‘implants and grafts’ initial encounter, other Escherichia coli (E. coli) as the cause of diseases classified elsewhere, and long term use of antibiotics. Plan of care (POC) orders included skilled nursing (SN) one time a week for nine weeks with three visits as needed (PRN) for PICC line management, change PICC line dressing weekly, and discontinue PICC line after last dose of antibiotics. a) The agency failed to provide proper PICC line management in accordance with accepted professional standard for Patient #1. During a home health visit on 10/8/24 around 7:30 a.m. registered nurse (RN) #9 was observed to perform a PICC line removal from the right arm of Patient #1. RN #9 was observed washing hands, gathering a sterile PICC line dressing kit, and setting Patient #1 in a comfortable position. RN #9 was observed to wash her hands, open up the sterile kit, put on sterile gloves, set up the sterile field, and remove the PICC line dressing. Following that, RN #9 washed her hands, applied new sterile gloves, cleansed around the PICC line insertion site with antiseptic solution. RN #9 pulled the PICC line out of the Patient #1’s right arm, set the line aside, and applied pressure to the site for approximately 3 minutes. RN #3 applied a sterile dressing and gave Patient #1 instructions on caring for the site over the next 24 hours. RN #9 did not measure the length of the PICC line before pulling it out of Patient #1’s arm. RN #3 did not inspect the tip of the PICC line after it was removed. Patient #1 threw the soiled dressings and PICC line in the garbage at the end of the visit. During an interview on 10/8/24 at approximately 7:45 a.m. at the home visit of Patient #1, RN #9 was unable to verify if she had previously documented a measurement of the length of Patient #1’s PICC line during previous home visits for PICC line dressing changes. Review of RN #9’s skilled visit notes between 8/30/24 and 10/8/24 showed no measurements of the PICC line during dressing changes. There was no documentation on the visit notes dated 9/3/24, 9/10/24, 9/16/24, 9/24/24, and 10/2/24, regarding a measurement between the PICC line skin puncture point and the crease point (where the PICC line bends toward the port) to see if the PICC line had moved. During an interview on 10/10/24 at 11:08 a.m., the director of nursing (DON) explained the agency’s PICC line procedure. The procedure was to measure the PICC line with each dressing change, document the length of the PICC line, hold pressure for 5 to 10 minutes following PICC line removal, and to inspect the tip of the PICC line after it was removed. The DON admitted this was the standard of care for PICC line management. 2. The clinical record for Patient #2 was reviewed on 10/8/24. Review of the plan of care for the certification period of 10/4/24 to 12/2/24 with a start of care date of 10/4/24. Relevant diagnosis include sepsis, unspecified organism and urinary tract infection. Plan of care orders include skilled nursing (SN) one time a week for six weeks with three visits as needed for PICC line management, soiled dressing, and flush PICC. a) The agency failed to provide proper PICC line management in accordance with accepted professional standard for Patient #2. During a home health visit with Patient #2 on 10/8/24 at approximately 10:20 a.m., the SA surveyors observed RN #2 provide a PICC line dressing change treatment. RN #3 performed hand hygiene, gathered supplies, and ensured Patient #2 was comfortable, lying in bed in the supine position with left arm extended. RN #3 set up the PICC line dressing kit, applied sterile gloves and a surgical mask, removed the soiled dressing, cleansed the PICC line port with alcohol swab for 30 seconds, and drew 2 vials of blood to send for testing per standing doctor’s orders. Following, RN #3 cleansed the port with another alcohol swab and capped the port with a sterile cap. RN #3 performed hand hygiene, cleansed the PICC line insertion site, and applied a sterile dressing. RN #3 did not use the measuring tool which was included in the PICC line dressing kit to measure the PICC line skin puncture point and the crease point to verify the line did not shift during the procedures. During an interview with RN #2 on 10/8/24 around 10:30 a.m., RN #3 was asked about measuring the length of the PICC line. RN #3 responded that she “eyeballed it and it was 1 centimeter.” RN #3 added Patient #2’s PICC line was inserted too far to show the measuring lines outside of the insertion site. RN #2 followed up with a statement about her personal nursing experience and “knowing exactly how long a PICC line is without needing to measure it.” During an interview on 10/8/24 at approximately 4:15 p.m., the DON stated RN #3 should not have eyeballed the measurement of the PICC line but should have gotten an actual measurement and documented it. During an interview on 10/10/24 at 11:08 a.m., the director of nursing (DON) explained the agency’s PICC line procedure. The procedure was to measure the PICC line with each dressing change, document the length of the PICC line, hold pressure for 5 to 10 minutes following PICC line removal, and to inspect the tip of the PICC line after it was removed. The DON admitted this was the standard of care for PICC line management.

A recertification survey in conjunction with a COVID-19 survey was completed on 10/21/21. Seven deficiencies were cited.

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 interview and record review, the agency failed to ensure an initial assessment was provided within 48 hours of referral for 2 of 12 active patient records reviewed (Patients #1 and #5). Findings include: 1. The clinical record for Patient #1 was reviewed on 10/18/21. The Plan of Care for the certification period dated 2/22/21 to 4/22/21 revealed a start of care date of 2/22/21; diagnoses included drug induced tremors, weakness, history of falling and history of traumatic fracture. Plan of Care orders included physical therapy (PT) visits weekly for two weeks then once every two weeks for assessment, training and exercise, occupational therapy (OT) visits weekly for four weeks for adaptive device recommendations, training and exercise and speech therapy (ST) for evaluation and treatment. a) The agency failed to conduct the start of care assessment within 48 hours of receipt of the referral. Review of the referral for Patient #1 revealed the agency had received the physician's referral for home health care services to provide PT, OT and ST on 2/16/21. Review of the start of care assessment dated 2/22/21 completed by PT #5 revealed the agency was four days late in starting services for Patient #1. Clinical record review revealed a communication note dated 2/18/21 completed by the Rehabilitation Director (RD) showing Patent #1 had a physician appointment on 2/18/21 and requested the start of care assessment be completed early the following week. Further review showed Patient #1's daughter was notified, however there was no evidence the agency had coordinated with the physician and obtained an order to delay services for Patient #1. 2. The clinical record for Patient #5 was reviewed on 10/19/21. The Plan of Care for the certification period dated 10/13 to 12/11/21 revealed a start of care date of 10/13/21; diagnoses included left patella fracture, polycythemia and history of falls. Plan of Care orders included PT visits once to twice weekly for three weeks for assessment, training and exercise and OT visits weekly for three weeks for training and exercise. a) The agency failed to conduct the start of care assessment within 48 hours of receipt of the referral. Review of the referral for Patient #5 revealed the agency had received the physician's referral for home health care services to provide PT and OT services on 10/9/21. Review of the start of care assessment dated 10/13/21 completed by PT #17 revealed the agency was two days late in starting services for Patient #5. Clinical record review revealed a communication note dated 10/11/21 completed by Intake Coordinator #14 showing PT #17 communicated with the office regarding Patient #5 having been in too much pain for the start of care assessment and wanting it to be delayed until 10/13/21. 3. During an interview on 10/21/21 at 10:59 a.m., the RD stated the agency expected that all patients were started within 24 to 48 hours from the referral unless the patient requested a late start of care. The RD stated the agency had not been contacting the physician about delays in starting service. The RD further stated the agency had documented communication with Patients #1 and #5 regarding a delay in service and the agency had not contacted the physician to obtain an order to delay the start of service.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure comprehensive assessments were performed in the last five days of a 60 day certification period for 4 of 12 active patient records reviewed (Patients #6, #8, #11, and #12). 3. The clinical record for Patient #11 was reviewed on 10/20/21. The Plan of Care for the certification period dated 8/5 to 10/3/21, revealed a start of care date of 8/5/21; diagnoses included multiple sclerosis and abnormalities of gait and mobility. Plan of Care orders included physical therapy (PT) visits weekly for muscle strengthening, standing balance, gait and aerobic capacity training. a) Record review revealed the agency failed to ensure Patient #11 received a comprehensive assessment during the last five days of the 60-day period. Review of a recertification comprehensive assessment dated 10/7/21 completed by PT #5 revealed Patient #11 was comprehensively assessed on 10/7/21 for the certification period dated 10/4 through 12/2/21, four days after the period began. During interview on 10/21/21 at 10:00 a.m., PT #5 stated he had completed the comprehensive recertification assessment late for Patient #11. PT #5 stated Patient #11 had declined his initial attempt to complete the comprehensive assessment within the last five days of the previous 60-day period and he had not documented his attempts to complete the assessment timely. 4. The clinical record for Patient #6 was reviewed on 10/19/2021. The Plan of Care for the certification period dated 9/10/21 to 11/08/2021, revealed a start of care date of 3/30/18; diagnoses included Hemiplegia and Diabetes. Plan of Care orders included CNA services three visits per week to provide assistance with activities of daily living (ADLs). a) Record review revealed the agency failed to ensure Patient #6 received a comprehensive assessment during the last five days of the 60-day period. Review of a recertification comprehensive assessment dated 9/17/21 completed by RN #15 revealed Patient #6 was comprehensively assessed on 9/17/21 for the certification period dated 9/10 to 11/8/21, seven days after the period began. During an interview on 10/21/21 at 9:08 a.m., RN #15 stated recertification assessments were to be completed the last five days of each 60-day period. RN #15 stated Patient #6's recertification assessment was late due to her having been on vacation during the last five days of the previous certification period and the agency having been unable to get another RN out timely. Findings Include: AGENCY POLICY According to the agency policy titled, "Reassessments/Recertification," dated 2009 (in pertinent parts): "Procedure 2. For each new episode of care, a comprehensive assessment will be completed no earlier than five (5) days before and no later than one (1) day before the calendar day on which the new episode of care will begin." 1. The clinical record for Patient #8 was reviewed on 10/19/21. The Plan of Care for the certification periods dated 8/9/21 to 10/7/21 and 10/8/21 to 12/6/21 revealed a start of care date of 8/4/20; diagnosis included uterine cancer, celiac disease, hypotension (low blood pressure), and polyneuropathy. Plan of care orders included skilled nursing (SN) services twice a week for nine weeks for intravenous (IV) infusion therapy and port care, and physical therapy (PT) services once a week for two weeks for home exercise program (HEP), and gait, balance, and strength training. a) The agency failed to ensure a comprehensive assessment was performed in the last five days of the 60 day certification period. Review of the clinical record for Patient #8 dated 8/9/21 to 10/7/21 revealed a new 60 day certification period started on 8/9/21. Further review of the clinical record revealed the 5 day reassessment window was from 8/4/21 to 8/8/21, however, RN #9 did not perform a reassessment until 8/9/21, the first day of the new certification period. During an interview on 10/21/21 at 10:11 a.m., RN #9 stated the agency expectation was to perform recertification assessments five days before the end of the certification period. She further stated she was not sure why Patient #8's reassessment occurred on the first day of the new certification period but she knew they were not supposed to perform the reassessment the day of the new certification started or after that. During an interview on 10/21/21 at 11:40 a.m., the Director of Clinical Services stated all recertification assessments were to be performed within five days of the new certification period beginning, and if that is not possible, the staff would see the patient as soon as it was possible. 2. The clinical record for Patient #12 was reviewed on 10/20/21. The Plan of Care for the certification periods dated 7/26/21 to 9/23/21 and 9/24/21 to 11/22/21 revealed a start of care date of 7/26/21; diagnoses included left hip fracture, fibromyalgia, hypertension, depression, and muscle weakness. Plan of Care orders included physical therapy (PT) services once a week for one week, twice a week for two weeks, and once a week for one week for range of motion exercises, gait training, strengthening exercises, endurance training, and adaptive device recommendations. a) The agency failed to ensure a comprehensive assessment was performed in the last five days of the 60 day certification period. Review of the clinical record for Patient #12 dated 9/24/21 to 11/22/21 revealed a new 60 day certification period started on 9/24/21. Further review of the clinical record revealed the 5 day reassessment window was from 9/19/21 to 9/23/21, however, PT #10 did not perform a reassessment until 9/24/21, the first day of the new certification period. During an interview on 10/21/21 at 9:01 a.m., PT #10 stated the recertification assessment was to be performed within five days of the new certification start, unless they cannot see the patient at that time, in which case the employee would perform a late certification and notify their quality assurance department.

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 interview and record review, the agency failed to ensure each patient received home health services in accordance with the written plan of care established and periodically reviewed by a physician for 2 of 12 active patients reviewed (Patients #3 and #9). Findings include: 1. The clinical record for Patient #3 was reviewed on 10/18/21. The Plan of Care for the certification period dated 7/20/21 to 9/17/21 revealed a start of care date of 3/22/21; diagnoses included encounter for adjustment and management of vascular access device, other acute osteomyelitis, left ankle and foot, atherosclerosis of native arteries of the left leg with ulceration of heel and midfoot, non pressure chronic ulcer of left heel and midfoot with necrosis of the bone, bacteremia, methicillin resistant Staphylococcus aureus infection, acute on chronic systolic (congestive) heart failure, and atrial fibrillation. Plan of Care orders included skilled nursing (SN) services twice weekly for assessment, education, wound care and pro thrombin/international ratio (PT/INR) lab draws each visit. Medication orders included: Coumadin (blood thinning medication) 4 milligrams (mg), one tablet on Sunday, Monday, Wednesday and Friday. a) The agency failed to provide PT/INR lab draws according to the physician approved Plan of Care. Review of SN visit note dated 7/27/21 completed by registered nurse (RN #12) revealed Patient #3 was taking 5 mg Coumadin five days a week, however the physician had ordered 4 mg Coumadin on Sunday, Monday, Wednesday and Friday (four days a week) according to the Plan of Care. Further review showed no evidence a PT/INR lab draw was conducted as ordered on the Plan of Care. Review of SN visit notes dated 7/30/21and 8/3/21 completed by RN #12 revealed Patient #3 was taking 5 mg Coumadin five days a week, however the physician had ordered 4 mg Coumadin four days a week according to the Plan of Care. Further review showed no evidence a PT/INR lab draws were conducted as ordered on the Plan of Care. During an interview on 10/21/21 at 9:40 a.m., RN #12 stated she was the case manager for Patient #3 and was responsible for ensuring physician orders were in place for the care provided. RN #12 stated she had only conducted PT/INR lab draws once weekly and reported results to the physician and did not obtain a physician order to change PT/INR lab draws every visit (twice weekly) to once weekly. 2. The clinical record for Patient #9 was reviewed on 10/19/21. The Plan of Care for the certification period dated, 8/28/21 through 10/26/21 revealed a start of care date of 4/30/21; diagnoses included encounter for adjustment of vascular access device, aftercare following digestive system surgery, Crohn's disease and peritonitis. Plan of Care orders included SN visits weekly for assessment, peripherally inserted central catheter (PICC) line dressing change and collection of blood labs; physical therapy (PT) visits once for evaluation and treatment and occupational therapy (OT) visits once for evaluation and treatment. a) The agency failed to provide care according to the physician approved Plan of Care following a hospitalization. Review of a resumption of care order dated 9/21/21 showed Patient #9 was to receive RN, PT and OT services following his potential discharge on 9/22/21 from the hospital for septic arthritis in the left wrist. Clinical record review revealed no evidence the agency had ensured a PT and OT evaluation had been conducted as ordered following Patient #9's discharge from the hospital for left wrist surgery. During an interview on 10/21/21 at 11:13 p.m., the rehabilitation director (RD) stated upon a resumption of care from the hospital, the intake department would inform the team about restarting services via an encrypted texting system, however the intake department would only schedule the resumption of care visit for the primary discipline. The RD further stated she could not see any communication notes or scheduled visits for the PT or OT within the electronic medical record (EMR) following Patient #9's discharge from the hospital.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to assure communication with all disciplines involved in the plan of care to meet the patient's needs for 2 of 3 patient records reviewed who sustained a fall (Patients #6 and #13) within the last five months. 2. The clinical record for Patient #6 was reviewed on 10/19/2021. The Plan of Care (POC) for the certification period dated 9/10/21 to 11/08/2021, revealed a start of care date of 3/30/18; diagnoses included Hemiplegia and Diabetes. Plan of Care orders included CNA services three visits per week to provide personal care. a) The agency failed to ensure documented coordination of care among team members after Patient #6 reported he had sustained a fall which resulted in bruising and abrasions to his back and right upper arm, as well as cuts and abrasions to the Patient's left leg and big toe. Review of CNA notes completed on 09/10/2021 showed CNA #19 documented Patient #6 reported he had fallen after the CNAs last visit, the CNA further documented she noted ‘abrasions and bruising on his [Patient #6] back...abrasions on his right upper arm..cuts and abrasions on his left leg and big toe..made nurse [DCS] aware.’ CNA #19 again documented during her visit with Patient #6 on 9/13/2021 ‘back bruising and abrasions are healing...cuts and abrasions are healing on lower left leg and big toe as well…’ Further, review of documentation completed on 9/17/2021, CNA #19 noted nurse [RN # 15] was also present for Patient #6 visit and that ‘she saw all of [Patient #6] skin breakdown and she did her assessment of him…’ Additional review of documentation completed by RN #15 on 9/17/2021 showed the RN noted the patient’s skin color, condition, temperature and moisture were within normal limits. During a joint interview with the Director of Clinical Services (DCS) and RN# 15 on 10/21/2021 at 0905, the DCS stated staff are expected to report falls to the nurse and/or the office. When a fall is reported the fall is documented as an adverse event and if the patient is hurt or has problems, the RN goes out to see the patient to provide an assessment. The DCS further stated the fall may have been reported as documented by CNA #19, however the DCS does not remember. The DCS was unable to provide documentation of the reported fall upon request and further acknowledged that she was responsible for ensuring the fall documentation was completed. Findings include: AGENCY POLICY According to the agency policy titled, "Care/Service Coordination," dated 2020 (in pertinent parts): "Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician will be responsible for facilitating communications about changes in the patient's status among the assigned personnel. - Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communication will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." 1. The clinical record for Patient #13 was reviewed on 10/20/21. The Plan of Care for the certification period dated 6/5/21 to 8/3/21 revealed a start of care date of 6/5/21; diagnoses included; paroxysmal atrial fibrillation, malignant neoplasm of the colon, malignant pleural effusion, sepsis, severe sepsis without septic shock, acute kidney failure, acute and chronic respiratory failure with hypoxia, pulmonary embolism without acute cor pulmonale, and diverticulitis of large intestine. Plan of Care orders included skilled nursing (SN) services one time a week for one week, two times a week for one week, three times a week for one week, two times a week for six weeks and one time a week for one week for assessment, education, ostomy care and wound vac care, occupational therapy (OT) services one time a week for five weeks for assessment, education, home exercise program (HEP), upper body strengthening, and activities of daily living training, physical therapy (PT) services one time a week for one week, one time a week for one week and one time a week for one week for assessment, education, balance, strength training, transfer training, gait training and HEP, and medical social worker (MSW) services one time a week for one week to assist with completion of Coloardo's Medical Orders for Scope of Treatment form. a) The agency failed to ensure documented coordination of care among team members after Patient #13 sustained a fall which resulted in Patient #13 hitting his head and possible dehiscence (the splitting or rusting open of a wound) of his abdominal wound. Review of the clinical record for Patient #13's clinical record revealed Patient #13 reported to registered nurse (RN) #9, during his 7/2/21 SN visit, that he had sustained a fall two days prior. RN #9 documented the patient reported he hit his head but did not lose consciousness. RN #9 documented Patient #13 was observed to have an open incision to his left lower quadrant (LLQ) (lower part of his abdomen) with ripped sutures, "possibly from fall." RN #9 documented she communicated with Patient #13's physician to inform the physician of the fall, ripped sutures and to receive new recommendations on wound care for Patient #13's left lower LLQ wound which was open due to the ripped sutures. Further review of the the clinical record revealed RN #9 documented communication with the MSW and at an agency meeting with no date or time of when the agency meeting occurred or which agency employees were present at the agency meeting or what information she communicated during this meeting. Review of communication notes dated 6/5/21 to 8/3/21 revealed no evidence of a communication note from RN #9 documenting Patient #13's fall with injury to Patient #13's primary PT (Employee #11), OT (Employee #18) or his primary RN (Employee #16). After the fall reported by RN #9, Patient #13's next PT and OT visit occurred on 7/8/21 (seven days after the fall occurred). There was no evidence in either the PT or OT note from 7/8/21 that RN #9 had communicated the fall to the PT or OT. Review of agency incident reports dated January 2021 to October 2021 revealed no evidence RN #9 completed an incident report for Patient #13's fall reported during the 7/2/21 SN visit. During an interview on 10/21/21 at 10:20 a.m., RN #9 stated she communicated the fall to Patient #13's team members via a telephone text system the agency used to communicate among team members named "Tiger Text." Furthermore, RN #9 stated she thought she had completed a fall report but could not be certain if she had. RN #9 acknowledged she also should have completed a communication note regarding Patient #13's fall in Patient #13's clinical record. During an interview on 10/21/21 at 9:23 a.m., PT #11 stated she was unsure if she could recall a specific fall for Patient #13 on 6/30/21. PT #11 stated "I know he has had falls." Furthermore, PT #11 stated the agency expectation was if a clinician was made aware of a fall the clinician was to complete an incident report. During an interview on 10/21/21 at 10:20 a.m. the Director of Clinical Services stated RN #9 should have documented in Patient #13's chart that she communicated to RN#16, PT#11 and OT #18 that Patient #13 sustained a fall on 6/30/21 which resulted in him hitting his head and was the possible source for the sutures opening in his LLQ wound. During an interview on 10/21/21 at 11:00 a.m., the Rehab Director stated she was unaware that Patient #13 had sustained a fall on 6/30/21. She stated the agency expectation was if a clinician was made aware of a fall with a patient, the clinician was to complete a fall report. Furthermore she stated if the Director of Operations could not find an incident report and did not appear to be in the agency electronic medical record. During an interview on 10/20/21 at 2:39 p.m., the Director of Operations stated there was no record of an incident report for a fall for Patient #13.

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 interview and record review, the agency failed to ensure communication with physicians involved in the Plan of Care for 4 of 12 active patient records reviewed (Patients #3, #8, and #12) and 1 of 5 discharged patient records reviewed (Patient #13). 3. The clinical record for Patient #8 was reviewed on 10/19/21. The Plan of Care for the certification periods dated 8/9/21 to 10/7/21 and 10/8/21 to 12/6/21 revealed a start of care date of 8/4/20; diagnosis included uterine cancer, celiac disease, hypotension (low blood pressure), and polyneuropathy. Plan of care orders included skilled nursing (SN) services twice a week for nine weeks for intravenous (IV) infusion therapy and port care, and physical therapy (PT) services once a week for two weeks for home exercise program (HEP), and gait, balance, and strength training. a) The agency failed to ensure the physician was notified when a recertification assessment was performed after the 60 day certification period had ended (late assessment). Review of the clinical record for Patient #8 dated 8/9/21 to 10/7/21 revealed a new 60 day certification period started on 8/9/21. Further review of the clinical record revealed the 5 day reassessment window was from 8/4/21 to 8/8/21, however, RN #9 did not perform a reassessment until 8/9/21, the first day of the new certification period. Further review of the clinical record revealed no evidence the physician was notified of the late recertification assessment performed on Patient #8. During an interview on 10/21/21 at 10:11 a.m., RN #9 stated the agency expectation was to perform recertification assessments five days before the end of the certification period. She further stated she should have notified the physician of the need for a late recertification and received orders from the physician to do so. During an interview on 10/21/21 at 11:40 a.m., the Director of Clinical Services stated all recertification assessments are to be performed within five days of the new certification period beginning, and if that is not possible, the staff would see the patient as soon as it was possible. She further stated that after the reassessment was finished then they would send the notification and verbal orders to the physician for approval. 4. The clinical record for Patient #12 was reviewed on 10/20/21. The Plan of Care for the certification periods dated 7/26/21 to 9/23/21 and 9/24/21 to 11/22/21 revealed a start of care date of 7/26/21; diagnoses included left hip fracture, fibromyalgia, hypertension, depression, and muscle weakness. Plan of Care orders included physical therapy (PT) services once a week for one week, twice a week for two weeks, and once a week for one week for range of motion exercises, gait training, strengthening exercises, endurance training, and adaptive device recommendations. a) The agency failed to ensure the physician was notified when a recertification assessment was performed after the 60 day certification period had ended (late assessment). Review of the clinical record for Patient #12 dated 9/24/21 to 11/22/21 revealed a new 60 day certification period started on 9/24/21. Further review of the clinical record revealed the 5 day reassessment window was from 9/19/21 to 9/23/21, however, PT #10 did not perform a reassessment until 9/24/21, the first day of the new certification period. Further review of the clinical record revealed no evidence the physician was notified of the late recertification assessment performed on Patient #8. During an interview on 10/21/21 at 9:01 a.m., PT #10 stated the recertification assessment was to be performed within five days of the new certification start, unless they cannot see the patient at that time, in which case the employee would perform a late certification and notify their quality assurance department. She further stated staff typically did not notify the physician with a late recertification assessment. During and interview on 10/21/21 at 11:00 a.m., the Rehab Director stated she was unaware of the regulation stating late recertification assessments needed to be communicated to the physician in order to receive interim orders for care. She further stated that up until now they had not been doing this. Findings Include: AGENCY POLICY According to the agency policy titled, "Physician Participation in Plan of Care," dated 2009 (in pertinent parts): "A physician will direct the care of every home health care patient admitted for service. The attending physician will certify that medical, skilled, rehabilitative, and social services provided by the organization are medically necessary and meets the requirements to be covered by Medicare. The attending physician will participate in the care planning process by initiating, reviewing and revising the plan of care (therapeutic and diagnostic orders). The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice." According to the agency policy titled, "Plan of Care and Interim Orders," dated 1/2021 (in pertinent parts): " B. Ongoing care- Interim /Verbal Orders 1. Agency clinical profession staff will maintain contact with the physician or designee regarding the client's changing condition and for clinical updates and physician requests for information. 3. Agency staff will document contacts and efforts to contact the physician or designee in the visit note or journal note as appropriate." 1. The clinical record for Patient #3 was reviewed on 10/18/21. The Plan of Care for the certification periods dated 7/20/21 to 9/17/21 and 9/18/21 to 11/16/21 revealed a start of care date of 3/22/21; diagnoses included encounter for adjustment and management of vascular access device, other acute osteomyelitis, left ankle and foot, atherosclerosis of native arteries of the left leg with ulceration of heel and midfoot, non pressure chronic ulcer of left heel and midfoot with necrosis of the bone, bacteremia, methicillin resistant Staphylococcus aureus infection, acute on chronic systolic (congestive) heart failure, and atrial fibrillation. Plan of Care orders included skilled nursing (SN) services two times a week for nine weeks and two times a week for five weeks for assessments, education, wound care and lab draws. a) The agency failed to ensure communication with the physician occurred when Patient #3 chose to stop taking Coumadin (a blood thinner) and instead chose to take aspirin. Review of the clinical record dated 7/20/21 to 9/17/21 revealed Patient #3's medications included: Coumadin (Warfarin) 4 mg, orally on Sunday, Monday, Wednesday and Friday, Doxazosin 8 mg, orally one time a day, Doxycycline Hyclate 100 mg, orally two times a day, Lutein 10 mg, orally daily, multivitamin, orally one time a day, Vitamin B-12 100 mcg, orally one time a day and Vitamin D3 1000 international units, orally one time a day. Review of the clinical record dated 9/18/21 to 11/16/21revealed Patient #3's medications included: Doxazosin 8 mg, orally once a day, Doxycycline Hyclate 100 mg, orally twice a day, multi-day multiple vitamin, orally one time a day, Vitamin B12 100 mcg, orally one time a day, and Vitamin D3 1250 mcg, orally one time a day. Review of SN Visit notes dated 7/20/21 to 9/17/21 revealed that RN #12 documented on 7/23/21, 7/27/21, 7/30/21, 8/3/21, 8/12/21, 8/16/21, 8/19/21, 8/23/21, 8/26/21, 8/30/21, 9/10/21, and 9/14/21 that Patient #3 was taking 5 mg of Coumadin 5 days a week. On 8/12/21, 8/16/21, 8/19/21, and 8/23/21 RN #12 documented Patient #3 "has chosen to stop his Coumadin and start an aspirin daily instead." Further review of the clinical record revealed no evidence that RN #12 or any agency employee had communicated with Patient #3's physician that Patient #3 had chosen to stop taking Coumadin and instead chose to take an aspirin. Further review revealed there was no evidence of an order for Patient #3 to discontinue Coumadin. During a home visit on 10/18/21 at 1:33 p.m., Patient #3 stated he was taking Doxazosin, Doxycycline and a "baby" aspirin. Patient #3 stated he chose to stop Coumadin and instead chose to take the aspirin as he felt his nose bleeds were being caused by the Coumadin. During an interview on 10/20/21 at 9:40 a.m., RN #12 stated Patient #3 chose to stop taking Coumadin himself and chose to take an aspirin instead. She stated Patient #3 reported he had informed his physician of this decision so she did not feel she also needed to inform the physician. RN #12 reviewed the Plan of Care for the certification period of 9/18/21 through 11/16/21 and acknowledged aspirin was not listed on his medication list. RN #12 stated as she was Patient #3's primary nurse it was her responsibility to ensure that the Plan of Care contained an accurate medication list for Patient #3. b) The RN #9 failed to ensure communication with the physician occurred to obtain an order to add a protective sheepskin padding to the wound care provided to Patient #3 left lower heel. Review of a Plan of Care for certification period dated 9/18/21 through 11/16/21 revealed wound care orders which included "clean with wound cleaner, apply purachol AG mepilex, kerlix and ace bandage." During a home visit on 10/18/21 at 1:33 p.m., RN #12 was observed during wound care to Patient #3's left lower heel ulcer. RN #12 was observed to glove and remove the previous dressing from Patient #3's wound, clean the wound, take wound measurements and apply Eucerin cream to Patient #3's left foot and ankle with RN #12 demonstrating care to not get any Eucerin cream in Patient #3 left heel wound. RN #12 then changed her gloves, applied puracol to the wound bed, a mepilex cover, sheepskin padding and wrapped the wound with kerilex and an ACE bandage. RN #12 stated she added the sheepskin padding to help reduce Patient #3's complaints of pain and to reduce pressure to Patient #3's left heel wound. During an interview on 10/21/21 at 9:40 a.m., RN #12 stated she added the sheepskin padding to the wound care she provided Patient #3 as she felt it was improving Patient #3's comfort and relieving pressure from his offloading boot that he wore on his left foot. RN#12 stated she did not make any attempts to seek an order from Patient #3's physician and acknowledged she should have obtained an order from Patient #3's physician to alter his wound care treatment. 2. The clinical record for Patient #13 was reviewed on 10/20/21. The Plan of Care for the certification period dated 6/5/21 to 8/3/21 revealed a start of care date of 6/5/21; diagnoses included paroxysmal atrial fibrillation, malignant neoplasm of the colon, malignant pleural effusion, sepsis, severe sepsis without septic shock, acute kidney failure, acute and chronic respiratory failure with hypoxia, pulmonary embolism without acute cor pulmonale, and diverticulitis of large intestine. Plan of Care orders included skilled nursing (SN) services one time a week for one week, two times a week for one week, three times a week for one week, two times a week for six weeks and one time a week for one week for assessment, education, ostomy care and wound vac care, occupational therapy (OT) services one time a week for five weeks for assessment, education, home exercise program (HEP), upper body strengthening, and activities of daily living training, physical therapy (PT) services one time a week for one week, one time a week for one week and one time a week for one week for assessment, education, balance, strength training, transfer training, gait training and HEP, and medical social worker (MSW) services one time a week for one week to assist with completion of Colorado's Medical Orders for Scope of Treatment form. a) The agency failed to ensure the OT communicated with Patient #13's physician to obtain a hold order for OT services. Review of physician orders dated 7/8/21revealed an order to add OT visits for one time a week for five weeks effective the week of 7/4/21 for ADL training, functional mobility training, transfers, adaptive equipment needs, HEP and safety. Review of OT notes dated 7/8/21 to 7/27/21 revealed OT #18 provided treatment on 7/8/21 and no further OT treatment was provided. Further review revealed OT #18 documented missed visits for 7/15/21, 7/23/21 and 7/27/21. OT #18 documented on 7/15/21 Patient #13's significant other requested to hold OT services for the week of 7/11/21 through 7/17/21 due to Patient #13's chemotherapy needs. On 7/23/21, OT #18 documented that he had called the patient to schedule Patient #13's OT visit and Patient #13's significant other stated that Patient #13's physician "requested to hold OT services at this time while going through chemo." On 7/27/21, OT #18 documented "OT services on hold per MD request, will resume when appropriate." Review of communication notes dated 6/5/21 to 8/3/21 revealed no evidence of communication between OT #18 and Patient #13's physician. Review of physician orders dated 6/5/21 to 8/3/21 revealed no evidence of a physician order to hold OT service. During an interview on 10/20/21 at 2:39 p.m., the Director of Operations stated she could not find any communication notes between OT #18 and Patient #13's physician. During an interview on 10/21/21 at 11:00 a.m., the Rehab Director stated she could not locate any communication notes between OT #18 and Patient #13's physician. b) The agency failed to ensure PT coordinated with the physician regarding orders to continue care. Review of Patient #13's clinical record dated 6/5/21 to 8/3/21 revealed Patient #13 was hospitalized from 6/24/21 through 6/29/21 for atrial fibrillation with rapid ventricular response (an irregular heartbeat where the heart is beating too fast). Review of Patient #13's physician orders dated 7/2/21 revealed a resumption of care order that included a PT order for one time a week for one week starting 7/4/21 written by RN #9. Further review of the physician orders revealed no evidence of further orders for continued PT treatment. Review of PT notes dated 6/22/21 to 7/29/21 revealed PT #11 provided an evaluation on 6/22/21 and PT treatments on 7/8/21, 7/15/21, and 7/22/21. Further review of PT orders revealed, PT #11 did not have physician orders for the treatments provided on 7/15/21 and 7/22/21. During an interview on 10/21/21 at 9:23 a.m., PT #11 stated she did not know why Patient #13 did not have PT orders to cover Patient #13's visits for 7/15/21 and 7/22/21. PT #11 stated she felt she would have requested orders for the entire certification period not for one week.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure certified nursing aides (CNAs) provided services as ordered by the physician, included in the plan of care, permitted to be performed under state law and were consistent with home health aide training for 1 of 1 patients reviewed receiving CNA services (Patient #6). Findings included: 1. The clinical record for Patient #6 was reviewed on 10/19/21. The Plan of Care (POC) for the certification period dated 9/10/21 to 11/8/21, revealed a start of care date of 3/30/18; diagnoses included Hemiplegia and Diabetes. Plan of Care orders included CNA services three visits per week to provide personal care including ‘may trim or file any long or uneven’ finger or toe nails. The POC also included instructions to apply a moisture barrier to the peri area as needed. a) The agency failed to ensure the CNA provided care in accordance with the written plan of care established by the physician; as permitted to be performed under state law; and consistent with the home health aide training. Review of CNA visit notes dated 10/16/21 completed by CNA #6, revealed Patient #6 received CNA visits three times weekly. CNA #6 documented she had trimmed and filed ‘most of’ the Patients' toenails and applied barrier cream to the abdomen, genital and buttock area. During interview with CNA #6 on 10/21/2021 at 10:55 a.m., the CNA stated she provided care for Patient #6 for the first time on 10/16/21 and that she had used toe nail clippers to clip the patient's toenails for this visit. When asked if there were certain patients a CNA was not permitted to trim or cut patient nails, CNA #6 stated she was not permitted to perform this task on diabetic patients. When asked if CNA #6 was aware Patient #6 had a diagnosis of diabetes. The CNA acknowledged she was aware and that she “should not have been trimming his nails”. She further stated she would no longer perform this task. Review of CNA visit notes dated 9/10/21 to 9/29/21 completed by CNA #19, revealed CNA #19 documented she completed ‘nail care’ for Patient #6's finger and toe nails on four of the seven visits. Furthermore, CNA #19 documented she had applied a protective barrier cream to Patient #6's coccyx on six of the seven visits she completed. Review of the Plan of Care dated 9/10/21, revealed there was no evidence that a protective barrier cream had been ordered or entered into the patient's medication administration record (MAR). During a joint interview with the Director of Clinical Services (DCS) and RN# 15 on 10/21/21 at 9:05 a.m., the DCS stated agency CNA’s could provide nail care, to include the trimming of nails, except on patients with a Diabetes diagnosis or at risk for bleeding. Both the DCS and RN #15 acknowledged Patient #6 had Diabetes and the CNAs should not have been trimming nails. During the same interview, RN #15 confirmed a barrier cream was not included in Patient #6's MAR and that the CNAs were applying an over the counter cream provided by the patient's wife. Both the DCS and RN #15 confirmed the CNAs should not apply any barrier cream that was not included in the MAR. b) The agency failed to ensure CNA services were provided as ordered by the physician. Review of clinical record documentation revealed two missed CNA visits for the certification period dated 9/10/21 to 11/8/21. During an interview with the DCS on 10/21/21 at 9:05 a.m., the DCS stated when a CNA was unable to provide their scheduled visit, they were to contact their direct supervisor, Clinical Supervisor #20 and that she would attempt to find replacement staff for the scheduled visit. Review of scheduled CNA visits to occur three times per week as ordered, showed Patient #6 only received two of three visits between 9/26/21 and 10/02/21. There was no documentation to show why Patient #6 did not receive the scheduled visit for this week. Additional record review also showed an ‘Aide Visit Note’ completed by CNA #19 on 9/19/21 where she noted a missed visit occurred on 9/15/21. CNA #19 documented she could not provide her scheduled visit with Patient #6 due to a plumbing issue in her home. The CNA attempted to contact Patient #6 but was unsuccessful. The CNA also noted she informed ‘the office’ in case Patient #6 called the agency about the CNAs whereabouts. She spoke to the patient the next day [9/16/21] and arranged to see Patient #6 on Friday, 9/17/21. There was no further documentation noted from the agency regarding the missed visit or any attempts to find replacement staff to ensure the visit was completed and the patient's needs had been met. During the interview with the DCS on 10/21/21 at 9:05 a.m., she stated she remembered “the loop had been closed” regarding the missed visit but did not believe it was documented.

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 interview and record review, the agency failed to provide a discharge summary to the physician within 5 days following patient discharge for 2 of 5 discharge records reviewed (Patients #13 and #14). Findings Include: 1. The clinical record for Patient #14 was reviewed on 10/20/21. The Plan of Care for the certification period dated 10/23/20 to 12/21/20 and 12/22/20 to 2/19/21 revealed a start of care date of 6/25/20; diagnoses included lymphedema, venous insufficiency, and abnormalities of gait and mobility. Plan of Care orders included physical therapy (PT) services once a week for seven weeks for range of motion exercises, strengthening, balance, and gait training, and a home exercise program (HEP). a) The agency failed to ensure a discharge summary was completed and sent to the physician within 5 business days of patient discharge. Review of the clinical record for the time period of 12/22/20 to 2/19/21 revealed Patient #14 was discharged from agency services on 12/28/20 after being admitted to the hospital with weakness and decreased endurance. Review of the discharge summary revealed the summary was completed on 12/28/20, however, PT #10 did not send the discharge summary to the physician until 1/7/21 (10 days later). During an interview on 10/21/21 at 9:08 a.m., PT #1 stated she did not know how long before she had to send the discharge notes to the physician, however, she stated the discharge summary was supposed to be sent to the physician within 24 hours of discharge. During an interview on 10/21/21 at 11:00 a.m., the Rehab Director stated she was not sure but she thought the discharge summary had to be sent to the physician within 24 hours of discharge. She further stated that in the case of Patient #14, the agency was waiting for the patient's insurance to notify the agency of benefits, and when the insurance declined home health services the agency discharged the patient.