Every finding on record at On the Way Home Care Inc

A complaint survey (complaint number 2023005004) was conducted on 07/24/2023 at One at Home - Dade. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to maintain documentation of the comprehensive assessment that must be updated and revised as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status for 1 out of 10 Sampled Patients (SP). SP#2 Findings include: Clinical record review of SP#2 conducted on 07/24/23 revealed a Comprehensive Assessment dated 07/12/2023 was documented for “other follow up”. The physician order dated 07/12/23 reads “Skilled nurse to perform wound care in sacral area three times per week”. Review of the Comprehensive Assessment dated 07/12/23 under section “Integumentary Status” was left blank. The comprehensive assessment omitted under section “Skilled Intervention” the interventions and assessment conducted during the visit of 07/12/2023/ Interview conducted with Administrator and Director of Nursing on 07/24/23 at approximately 5:00 pm. The Administrator and Director of Nursing reviewed the comprehensive assessment for SP#2 and acknowledged that the information on the section “Skilled Intervention” did not reflect the status of the patient.

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 clinical record review and interview, the home health agency failed to promptly alert the relevant physician(s) to any changes that suggest the plan of care should be altered for 1 out of 4 Sampled Patients (SP). SP#1 Findings include: Clinical record review of SP#1 conducted on 07/24/23 contained a Plan of Care (POC) for certification period 05/27/23 to 07/25/23 that reads for skilled nurse to provide daily insulin(s) administration at PM with dinner and caregiver is able to provide AM (morning) and Noon dose of insulin(s). The Plan of Care reads Novolog 2 units three times a day before breakfast, lunch, and dinner; and Lantus 10 units daily with dinner. Review of the licensed practical nurse service notes for date range 05/27/23 to 07/21/23 revealed the Novolog and Lantus insulin(s) were administered at a range time frame of 12:00 pm and 1:00 pm. The clinical record omitted documentation for the reason the nurse provides Lantus insulin administration between 12:00 pm and 1:00 pm and not as ordered on POC for dinner time. Further review of the record omitted documentation of notifying the ordering physician of the change in the time of the Lantus insulin administration and that it was approved. Telephone interview conducted with Licensed Practical Nurse (providing care to SP#1) on 07/24/23 at 2:20 PM stated that she provides Novolog 2 units and Lantus 10 units between noon and 2 PM. The Licensed Practical Nurse state that she was not aware if the patient’s family provides insulin in the morning or afternoon. Interview conducted with the Administrator and Director of Nursing on 07/24/23 at 3:17 PM stated the staff was called by the Case Manager and stated that around April, the patient’s caregiver requested to the nurse to switch the PM visit to Noon visit due to the caregiver’s having a change at work. The nurse did not notify the Case Manager of the change and therefore the POC continued to reflect for the nurse to visit in the PM visit instead of the Noon. The Administrator added that at this time, the Case Manager will contact the ordering physician to notify of the need to change the nurse visit from PM to Noon.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate in 1 out 4 Sampled Patients (SP). SP#1 Findings include: Clinical record review of SP#1 conducted on 07/24/23 contained a Plan of Care (POC) for certification period 05/27/23 to 07/25/23 that reads for skilled nurse to provide daily insulin(s) administration at PM with dinner and caregiver is able to provide AM (morning) and Noon dose of insulin(s). The Plan of Care reads Novolog 2 units three times a day before breakfast, lunch, and dinner; and Lantus 10 units daily with dinner. Review of the licensed practical nurse service notes for date range 05/27/23 to 07/21/23 revealed the Novolog and Lantus insulin(s) were administered at a range time frame of 12:00 pm and 1:00 pm. The clinical record omitted documentation for the reason the nurse provides Lantus insulin administration between 12:00 pm and 1:00 pm and not as ordered on POC for dinner time. Further review of the record omitted documentation of notifying the ordering physician of the change in the time of the Lantus insulin administration and that it was approved. Telephone interview conducted with Licensed Practical Nurse (providing care to SP#1) on 07/24/23 at 2:20 PM stated that she provides Novolog 2 units and Lantus 10 units between noon and 2 PM. The Licensed Practical Nurse state that she was not aware if the patient’s family provides insulin in the morning or afternoon. Interview conducted with the Administrator and Director of Nursing on 07/24/23 at 3:17 PM stated the staff was called by the Case Manager and stated that around April, the patient’s caregiver requested to the nurse to switch the PM visit to Noon visit due to the caregiver’s having a change at work. The nurse did not notify the Case Manager of the change and therefore the POC continued to reflect for the nurse to visit in the PM visit instead of the Noon. The Administrator added that at this time, the Case Manager will contact the ordering physician to notify of the need to change the nurse visit from PM to Noon.

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 review and interview, the home health agency staff failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 1 out 4 Sampled Patients (SP). SP#1 Findings include: Clinical record review of SP#1 conducted on 07/24/23 contained a Plan of Care (POC) for certification period 05/27/23 to 07/25/23 that reads for skilled nurse to provide daily insulin(s) administration at PM with dinner and caregiver is able to provide AM (morning) and Noon dose of insulin(s). The Plan of Care reads Novolog 2 units three times a day before breakfast, lunch, and dinner; and Lantus 10 units daily with dinner. Review of the licensed practical nurse service notes for date range 05/27/23 to 07/21/23 revealed the Novolog and Lantus insulin(s) were administered at a range time frame of 12:00 pm and 1:00 pm. The clinical record omitted documentation for the reason the nurse provides Lantus insulin administration between 12:00 pm and 1:00 pm and not as ordered on POC for dinner time. Further review of the record omitted documentation of notifying the ordering physician of the change in the time of the Lantus insulin administration and that it was approved. Telephone interview conducted with Licensed Practical Nurse (providing care to SP#1) on 07/24/23 at 2:20 PM stated that she provides Novolog 2 units and Lantus 10 units between noon and 2 PM. The Licensed Practical Nurse state that she was not aware if the patient’s family provides insulin in the morning or afternoon. Interview conducted with the Administrator and Director of Nursing on 07/24/23 at 3:17 PM stated the staff was called by the Case Manager and stated that around April, the patient’s caregiver requested to the nurse to switch the PM visit to Noon visit due to the caregiver’s having a change at work. The nurse did not notify the Case Manager of the change and therefore the POC continued to reflect for the nurse to visit in the PM visit instead of the Noon. The Administrator added that at this time, the Case Manager will contact the ordering physician to notify of the need to change the nurse visit from PM to Noon.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 4 Sampled Patients (SP). SP#1 Findings include: Clinical record review conducted on 07/24/23 of SP#1 revealed patient is receiving Skilled Nursing (SN) and Home Health Aide (HHA) services provided by the home health agency. The provider failed to demonstrate that HHA supervisions were conducted every 14 days from last documented supervision 06/05/23 and 07/03/23 which is an interval of 28 days. Interview conducted with the Administrator on 07/24/23 at 1:50 PM confirmed findings, failure of the provider to demonstrate onsite supervision of the home health aide every 14 days. The Administrator added that the staff must have erased the calendar for the time the patient was not serviced and just resumed as scheduled the supervisory visit. Review of the agency's policy titled "Home Health Aide Supervision" reads "All home health aide supervisory visits will be made at least every 14 days. The Agency will conduct the 14 day supervisory visit during an on-site visit, in person visit.”

An Extended Complaint Survey for complaint #2021014983 was conducted on November 09, 2021 to November 12, 2021 at One At Home-Dade. The Home Health Agency was found to be in non-compliance with Conditions of Participation for 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

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 staff interview, the provider failed to submit the encoded OASIS (Outcome and Assessment Information Set) data that must accurately reflect the patient's status at the time of assessment for 1 out of 3 Sampled Patients (SP). SP#3 Findings include: Record review of SP#3 revealed a Resumption of Care OASIS Assessment completed with date 08/18/21. Review of the OASIS assessment under section (M1021) Primary Diagnosis revealed as “Pressure ulcer of sacral region, Stage 4 O/E (onset/exacerbation) date: 08/16/21. Further review under section “Integumentary Status” reads “wound”, under (M1306)-Does this patient have at least one unhealed pressure ulcer /injury at stage 2 or higher or designated as unstageable? Answer was no. At (M1324) Stage of most problematic unhealed pressure ulcer / injury that is stageable? Answer was Not Applicable - Patient has no pressure ulcers / injuries or no stageable pressure ulcers/injuries. Review of the submission validation report dated 09/10/21 revealed the assessment dated 08/18/21 was submitted and status accepted. Interview conducted with the Administrator and Director of Nursing (DON) on 11/10/21 between 4:49 pm and 4:55 pm. The Administrator and DON reviewed the OASIS assessment for SP#3 dated 08/18/21. The Administrator acknowledged that (M1306) was answered incorrectly and added that under the wound care worksheet and treatment orders the nurse described the sacral wound and the wound care as ordered.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interviews, the provider failed to demonstrate the patient and/or caregiver participated in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to revising the plan of care; the frequency of visits; any factors that could impact treatment effectiveness; and any changes in the care to be furnished for 1 out 3 Sampled Patients (SP). (SP#3) Findings include: Review of clinical record for SP#3 revealed an update to the Plan of Care dated 08/28/21 that reads “SN (skilled nurse) to perform wound care to sacrum ulcer daily: cleanse with normal saline, apply skin prep to peri wound area, apply Aquacel AG dressing to wound bed, cover with Allevyn border change dressing daily and as needed”. A physician order dated 09/02/21, that reads “Sacral pressure injury stage 4 care: Cleanse with normal saline, apply Triad Hydrophilic wound paste, cover with gauze and pad 3 x wk (three times a week) and prn (as needed). On 09/08/21 a physician order reads “SN to perform wound care to sacrum ulcer daily: cleanse wound with normal saline, apply skin prep to periwound area, apply Aquacel AG dressing to wound bed cover with Allevyn bordered dressing, change daily and as needed. Further review of the record omitted evidence in the patient's medical record that as changes occur in the patient's care, the patient/caregiver were consulted and consented to a change to the plan of care, whether initiated by the Home Health Agency/physician or at the request of the patient, documentation in the clinical record did not indicate whether the patient was informed of and agreed to the changes. Telephone interview was conducted with SP#3’s caregiver on 11/12/21 between.11:22 am to 12:11 pm. The caregiver stated that SP#3 was receiving wound care daily by the nurse from the Home Health Agency. The SP#3’s caregiver states that the wound care was changed from daily to 3 times a week as of 09/03/21, adding that the nurse did continue to go out almost daily because the wound had drainage and therefore the dressing required to be changed, so the nurse actually only did not go like one day before the wound care was changed back again to daily after she called the agency and informed them that she did not agree with the 3 times a week frequency. The caregiver states the visiting nurse informed her during the last daily visit because the wound frequency was changed, and she was notified by the case manager. The caregiver states that she was not in agreement due to the wound having too much drainage. The caregiver states she called the Home Health Agency immediately to speak to the case manager and was not able to, but the on-call person informed her that in the system it seemed that the frequency was already changed back to daily.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate it sent all necessary medical information pertaining to the patient's current course of illness and treatment to the receiving facility or health care practitioner to ensure the safe and effective transition of care for 1 out 3 Sampled Patients (SP). (SP#3) Findings include: Clinical record review for SP#3 revealed that on 08/11/21 a transfer to an inpatient facility was completed. The documentation revealed the patient was admitted to hospital [hospital name] due to low hemoglobin levels. A second transfer to an inpatient facility was completed on 10/26/21 and the documentation revealed the patient was admitted to hospital [hospital name] due to wound deterioration. Further review of the clinical record revealed no documentation of a transfer summary completed on 08/11/21 and 10/26/21 providing the receiving facility patient's current course of illness and treatment to ensure the safe and effective transition of care. Interview conducted with the Administrator and Director of Nursing (DON) on 11/12/21 between 4:29 pm and 4:49 pm. The Administrator reviewed the clinical record for SP#3 and stated that only the patient’s physician was notified of the transfer to hospital via a modified order. The Administrator acknowledges that no transfer summaries were conducted for 08/11/21 and 10/26/21 transfers to inpatient facility.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: This CONDITION is not met as evidence by: Based on interview, clinical record review and review of policies and procedures, it was determined that the Home Health Agency (HHA) failed to ensure the care follows the written plan of care established by the physician (Refer to G-578) and provide treatments only as ordered by a physician (Refer to G-580). The HHA failed to consult the physician about the patient's condition or needs that suggest the plan of care should be altered (Refer to G-590) and failed to inform of any revision to the plan of care due to a change in patient health status (Refer to G-596). The cumulative effect of these systemic practices resulted in the agency’s inability to ensure that the patient's nursing needs were met.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to ensure the care follows the written plan of care (POC) established by the physician on 1 out of 3 Sampled Patients (SP). (SP#2) Findings include: Clinical record review conducted on 11/09/21 to 11/10/21 of SP#2 contained a Plan of Care for certification periods 08/03/21 to 10/01/21 and 10/02/21 to 11/30/21 that under section "Orders for Discipline and Treatments" reads "SN (skilled nurse) record wound size at start of care and at least weekly thereafter.” Review of the SN note for service dates 08/03/21 sacral wound measuring 3 cm- Length x 3 cm- Width x 0.2 cm-Deep. Further review revealed no measurement taken for date range of 08/09/21 to 10/06/21. The SP#2 was admitted to the hospital on 10/11/21. A resumption of care assessment was completed on 10/25/21 and no documentation of the sacral wound measurement completed. Further review of the SN notes for service dates 10/30/21 to 11/09/21 revealed no sacral wound measurements obtained. Telephone interview conducted with the Registered Nurse (RN) providing care to SP#2 on 11/10/21 between 3:59 pm to 4:04 pm acknowledged findings made by the surveyor, clarifying that she did not document the measurements. The RN stated that she maintains a weekly measurement log and can provide it for review. As of 11/12/21 no documentation from the RN was received to review.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interviews, the provider failed to administer treatments only as ordered by a physician for 1 out of 3 Sampled Patients (SP). (SP#3) Findings include: Review of clinical record for SP#3 revealed an update to the Plan of Care dated 08/28/21 that reads “SN (skilled nurse) to perform wound care to sacrum ulcer daily: cleanse with normal saline, apply skin prep to peri wound area, apply Aquacel AG dressing to wound bed, cover with Allevyn border change dressing daily and as needed” and signed by the physician on 09/03/21. A physician order dated 09/02/21, that reads “Sacral pressure injury stage 4 care: Cleanse with normal saline, apply Triad Hydrophilic wound paste, cover with gauze and pad 3 x wk (three times a week) and prn (as needed) and signed by the physician on 09/03/21. On 09/08/21 a physician order reads “SN to perform wound care to sacrum ulcer daily: cleanse wound with normal saline, apply skin prep to periwound area, apply Aquacel AG dressing to wound bed cover with Allevyn bordered dressing, change daily and as needed with physician signature in blank. Telephone interview was conducted on 11/11/21 between 4:34 pm to 5:02 pm with SP#3’s ordering physician’s assistant. As per assistant the home health agency last sent a physician order dated 09/02/21 and it was signed by the physician and dated 09/03/21. The assistant stated that they have not received any further documentation from the home health agency after 09/02/21. Telephone interview was conducted on 11/11/21 between 5:23 pm to 5:32 pm with the Case Manager that wrote up the physician order dated 09/08/21. The Case Manager acknowledges that she did not speak with the physician to obtain the verbal order from him to make the change to SP#3’s wound care. The Case Manger stated that she wrote up the order to reflect the last wound care order before the change of 09/02/21. Telephone interview was conducted on 11/12/21 between 12:41 pm to 1:12 pm with the Registered Nurse (RN) providing care to SP#3. The RN stated that the wound care change on 09/02/21 to provide three times a week visit was not the best for the patient because the wound had too much drainage and required at least daily dressing change. The RN added that she reported this to the Case Manager, and she recommended to go back to the previous wound care order of daily. The RN started providing the same wound care as before as of 09/08/21.

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 provider failed to consult the physician about the patient's condition or needs that suggest the plan of care should be altered for 1 out 3 Sampled Patients (SP). (SP#3) Findings include: Review of the clinical record for SP#3 revealed patient’s sacral wound on 08/18/21 was measuring 8 cm - Length x 6 cm - Width x 0.5 cm - Deep and by 09/14/21 the wound had increased in size as documented by the Registered Nurse as of 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep. The record omitted documentation that the physician was notified of the patient’s wound condition to have increased. On 10/12/21 skilled nurse service note revealed documentation of sacral wound measuring 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep and under additional information: “measures have increased. 30% necrotic tissue (slough) painful wound”. The clinical record contained physician communications effective 10/13/21 requesting a social worker evaluation, and on 10/14/21, 10/15/21, 10/19/21, 10/20/21, 10/26/21 a wound care specialist evaluation and treatment. On 10/27/21 a communication physician order documenting that SP#3 was admitted to the hospital due to “sacrum wound deterioration.” Further review of the clinical record revealed documentation of pictures taken for the sacral wound on dates as of 10/12/21, 10/19/21, 10/22/21 and 10/26/21 with notable deterioration of the sacrum wound, review of the nursing notes for stated dates revealed no documentation of wound being measures at each visit. The nursing note for date 10/12/21 revealed documentation of “measures have increased”. Telephone interview was conducted on 11/11/21 between 5:23 pm to 5:32 pm with the Case Manager for SP#3. The Case Manager stated that she was calling the physician’s office around the middle of October but could never speak with anyone. The Case Manager then added that she was informed that she was calling the wrong office and was provided with the new phone number to the location where the physician provides care to SP#3. The Case Manager added that when she called the new number, she was informed that the physician was out on vacation and therefore was not able to speak with anyone about the patient’s condition. Telephone interview was conducted on 11/12/21 between 12:41 pm to 1:12 pm with the Registered Nurse (RN) providing care to SP#3. The RN stated that she did not call the SP#3’s physician to notify of the wound status. The RN stated that she only informed the Case Manager, and she was the one to call the physician. The RN stated that Case Manager informed her that she called the physician’s office but would get no answer or she would be left on hold for long periods of time and therefore was never able to speak with someone at the physician’s office.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on record review and interviews, the provider failed to inform of any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the Home Health Agency (HHA) plan of care for 1 out of 3 Sampled Patients (SP). (SP#3) Findings include: Review of clinical record for SP#3 revealed an update to the Plan of Care dated 08/28/21 that reads “SN (skilled nurse) to perform wound care to sacrum ulcer daily: cleanse with normal saline, apply skin prep to peri wound area, apply Aquacel AG dressing to wound bed, cover with Allevyn border change dressing daily and as needed” and signed by the physician on 09/03/21. A physician order dated 09/02/21, that reads “Sacral pressure injury stage 4 care: Cleanse with normal saline, apply Triad Hydrophilic wound paste, cover with gauze and pad 3 x wk (three times a week) and prn (as needed) and signed by the physician on 09/03/21. On 09/08/21 a physician order reads “SN to perform wound care to sacrum ulcer daily: cleanse wound with normal saline, apply skin prep to periwound area, apply Aquacel AG dressing to wound bed cover with Allevyn bordered dressing, change daily and as needed with physician signature in blank. The clinical record omitted documentation that the HHA explained to the patient and/or caregiver that a change to the plan of care has occurred and how the change will impact the care delivered by the HHA, and that the revised plan of care was shared with all relevant physicians providing care to the patient. Telephone interview was conducted on 11/11/21 between 4:34 pm to 5:02 pm with SP#3’s ordering physician’s assistant. As per assistant the home health agency last sent a physician order dated 09/02/21 and it was signed by the physician and dated 09/03/21. The assistant stated that they have not received any further documentation from the home health agency after 09/02/21. Telephone interview was conducted on 11/11/21 between 5:23 pm to 5:32 pm with the Case Manager for SP#3. The Case Manager stated that she was calling the physician’s office around the middle of October but could never speak with anyone. The Case Manager then added that she was informed that she was calling the wrong office and was provided with the new phone number to the location where the physician provides care to SP#3. The Case Manager added that when she called the new number, she was informed that the physician was out on vacation and therefore was not able to speak with anyone about the patient’s condition. Telephone interview was conducted with SP#3’s caregiver on 11/12/21 between 11:22 am to 12:11 pm. The caregiver stated that SP#3 was receiving wound care daily by the nurse from the Home Health Agency. The SP#3’s caregiver states that the wound care was changed from daily to 3 times a week as of 09/03/21, adding that the nurse did continue to go out almost daily because the wound had drainage and therefore the dressing required to be changed, so the nurse actually only did not go like one day before the wound care was changed back again to daily after she called the agency and informed them that she did not agree with the 3 times a week frequency. The caregiver states the visiting nurse informed her during the last daily visit because the wound frequency was changed, and she was notified by the case manager. The caregiver states that she was not in agreement due to the wound having too much drainage. The caregiver states she called the Home Health Agency immediately to speak to the case manager and was not able to, but the on-call person informed her that in the system it seemed that the frequency was already changed back to daily.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: This CONDITION is not met as evidence by: Based on interview, clinical record review and review of policies and procedures, it was determined that the Home Health Agency (HHA) failed to maintain ongoing interdisciplinary assessment of the patient (Refer to G-706) and failed to maintain communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care (Refer to G-718). The cumulative effect of these systemic practices resulted in the agency’s inability to ensure that the patient's nursing needs would be met.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to maintain ongoing interdisciplinary assessment of the patient for 1 out 3 Sampled Patients (SP). (SP#3) Findings include: Review of the clinical record for SP#3 revealed patient’s sacral wound on 08/18/21 was measuring 8 cm - Length x 6 cm - Width x 0.5 cm - Deep and by 09/14/21 the wound had increased in size as documented by the Registered Nurse as 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep. The record omitted documentation that the physician was notified of the patient’s wound condition to have increased. On 10/12/21 skilled nurse service note revealed documentation of sacral wound measuring 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep and under additional information: “measures have increased. 30% necrotic tissue (slough) painful wound”. The clinical record contained physician communications effective 10/13/21 requesting a social worker evaluation, and on 10/14/21, 10/15/21, 10/19/21, 10/20/21, 10/26/21 a wound care specialist evaluation and treatment. On 10/27/21 a communication physician order documenting that SP#3 was admitted to the hospital due to “sacrum wound deterioration.” Further review of the clinical record revealed documentation of pictures taken for the sacral wound on dates as of 10/12/21, 10/19/21, 10/22/21 and 10/26/21 with notable deterioration of the sacrum wound, review of the nursing notes for stated dates revealed no documentation of wound being measured at each visit. The nursing note for date 10/12/21 revealed documentation of “measures have increased”. Telephone interview was conducted on 11/11/21 between 4:34 pm to 5:02 pm with SP#3’s ordering physician’s assistant. As per assistant the home health agency last sent a physician order dated 09/02/21 and it was signed by the physician and dated 09/03/21. The assistant stated that they have not received any further documentation from the home health agency after 09/02/21. The assistant informed that SP#3 was being seen monthly by a nurse practitioner that was assigned to SP#3 after last hospital admission in August 2021. The assistant explained that the nurse practitioner evaluates the patient in the home and provides visit note documentation to the physician. The assistant stated that SP#3 has not been to the office in a while and currently are doing telehealth visits only. Telephone interview was conducted on 11/11/21 between 5:23 pm to 5:32 pm with the Case Manager for SP#3. The Case Manager stated that she was calling the physician’s office around the middle of October but could never speak with anyone. The Case Manager then added that she was informed that she was calling the wrong office and was provided with the new phone number to the location where the physician provides care to SP#3. The Case Manager added that when she called the new number, she was informed that the physician was out on vacation and therefore was not able to speak with anyone about the patient’s condition. Telephone interview was conducted with SP#3’s caregiver on 11/12/21 between 11:22 am to 12:11 pm. The caregiver explained that the nurse practitioner stated visiting monthly after SP#3 was discharged from the hospital back in August. The caregiver stated that the nurse practitioner would assess the patient but did not assess the wound due to nurse practitioner being aware of home health agency providing daily wound care. The caregiver added that she requested from nurse practitioner to have a wound care specialist evaluate SP#3’s sacrum wound since it was being reported by visiting nurse that the wound was deteriorating. The nurse practitioner agreed to get a wound care specialist evaluate the wound when he last visited on Monday (10/25/21) but the patient required to be taken to the hospital because she was not feeling well on 10/27/21.

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 clinical record review and interview, the provider failed to maintain communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care for 1 out of 3 Sampled Patients (SP). (SP#3) Findings include: Review of the clinical record for SP#3 revealed patient’s sacral wound on 08/18/21 was measuring 8 cm - Length x 6 cm - Width x 0.5 cm - Deep and by 09/14/21 the wound had increased in size as documented by the Registered Nurse as 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep. The record omitted documentation that the physician was notified of the patient’s wound condition to have increased. On 10/12/21 skilled nurse service note revealed documentation of sacral wound measuring 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep and under additional information: “measures have increased. 30% necrotic tissue (slough) painful wound”. The clinical record contained physician communications effective 10/13/21 requesting a social worker evaluation, and on 10/14/21, 10/15/21, 10/19/21, 10/20/21, 10/26/21 a wound care specialist evaluation and treatment. On 10/27/21 a communication physician order documenting that SP#3 was admitted to the hospital due to “sacrum wound deterioration.” Further review of the clinical record revealed documentation of pictures taken for the sacral wound on dates as of 10/12/21, 10/19/21, 10/22/21 and 10/26/21 with notable deterioration of the sacrum wound, review of the nursing notes for stated dates revealed no documentation of wound being measures at each visit. The nursing note for date 10/12/21 revealed documentation of “measures have increased”. Telephone interview was conducted on 11/11/21 between 4:34 pm to 5:02 pm with SP#3’s ordering physician’s assistant. As per assistant the home health agency last sent a physician order dated 09/02/21 and it was signed by the physician and dated 09/03/21. The assistant stated that they have not received any further documentation from the home health agency after 09/02/21. The assistant informed that SP#3 was being seen monthly by a nurse practitioner that was assigned to SP#3 after last hospital admission in August 2021. The assistant explained that the nurse practitioner evaluates the patient in the home and provides visit note documentation to the physician. The assistant stated that SP#3 has not been to the office in a while and currently are doing telehealth visits only. Telephone interview was conducted on 11/11/21 between 5:23 pm to 5:32 pm with the Case Manager for SP#3. The Case Manager stated that she was calling the physician’s office around the middle of October but could never speak with anyone. The Case Manager then added that she was informed that she was calling the wrong office and was provided with the new phone number to the location where the physician provides care to SP#3. The Case Manager added that when she called the new number, she was informed that the physician was out on vacation and therefore was not able to speak with anyone about the patient’s condition. The Case Manager acknowledged that she was not aware of the nurse practitioner visiting monthly and is not aware if the nurse practitioner works with the SP#3 physician. The Case Manager states that the nurse practitioner sent on 10/26/21 a physician order for Foley Cather but due to SP#3 being admitted to the hospital on 10/27/21, the order was not completed. Telephone interview was conducted with SP#3’s caregiver on 11/12/21 between 11:22 am to 12:11 pm. The caregiver explained that the nurse practitioner stated visiting monthly after SP#3 was discharged from the hospital back in August. The caregiver stated that the nurse practitioner would assess the patient but did not assess the wound due to nurse practitioner being aware of home health agency providing daily wound care. The caregiver added that she requested from nurse practitioner to have a wound care specialist evaluate SP#3’s sacrum wound since it was being reported by visiting nurse that the wound was deteriorating. The nurse practitioner agreed to get a wound care specialist evaluate the wound when he last visited on Monday (10/25/21) but the patient required to be taken to the hospital because she was not feeling well on 10/27/21. Telephone interview was conducted on 11/12/21 between 12:41 pm to 1:12 pm with the Registered Nurse (RN) providing care to SP#3. The RN stated that she did not call the SP#3’s physician to notify of the wound status. The RN stated that she only informed the Case Manager, and she was the one to call the physician. The RN stated that Case Manager informed her that she called the physician’s office but would get no answer or she would be left on hold for long periods of time and therefore was never able to speak with someone at the physician’s office.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the clinical manager failed to coordinate patient care for 1 out 3 Sampled Patients (SP). (SP#3) Findings include: Review of the clinical record for SP#3 revealed patient’s sacral wound on 08/18/21 was measuring 8 cm - Length x 6 cm - Width x 0.5 cm - Deep and by 09/14/21 the wound had increased in size as documented by the Registered Nurse as 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep. The record omitted documentation that the physician was notified of the patient’s wound condition to have increased. On 10/12/21 skilled nurse service note revealed documentation of sacral wound measuring 10 cm - Length x 9.5 cm - Width x 0.5 cm – Deep and under additional information: “measures have increased. 30% necrotic tissue (slough) painful wound”. The clinical record contained physician communications effective 10/13/21 requesting a social worker evaluation, and on 10/14/21, 10/15/21, 10/19/21, 10/20/21, 10/26/21 a wound care specialist evaluation and treatment. On 10/27/21 a communication physician order documenting that SP#3 was admitted to the hospital due to “sacrum wound deterioration.” Further review of the clinical record revealed documentation of pictures taken for the sacral wound on dates as of 10/12/21, 10/19/21, 10/22/21 and 10/26/21 with notable deterioration of the sacrum wound, review of the nursing notes for stated dates revealed no documentation of wound being measures at each visit. The nursing note for date 10/12/21 revealed documentation of “measures have increased”. Telephone interview was conducted on 11/11/21 between 4:34 pm to 5:02 pm with SP#3’s ordering physician’s assistant. As per assistant the home health agency last sent a physician order dated 09/02/21 and it was signed by the physician and dated 09/03/21. The assistant stated that they have not received any further documentation from the home health agency after 09/02/21. The assistant informed that SP#3 was being seen monthly by a nurse practitioner that was assigned to SP#3 after last hospital admission in August 2021. The assistant explained that the nurse practitioner evaluates the patient in the home and provides visit note documentation to the physician. The assistant stated that SP#3 has not been to the office in a while and currently are doing telehealth visits only. Telephone interview was conducted on 11/11/21 between 5:23 pm to 5:32 pm with the Case Manager for SP#3. The Case Manager stated that she was calling the physician’s office around the middle of October but could never speak with anyone. The Case Manager then added that she was informed that she was calling the wrong office and was provided with the new phone number to the location where the physician provides care to SP#3. The Case Manager added that when she called the new number, she was informed that the physician was out on vacation and therefore was not able to speak with anyone about the patient’s condition. The Case Manager acknowledged that she was not aware of the nurse practitioner visiting monthly and is not aware if the nurse practitioner works with the SP#3 physician. The Case Manager states that the nurse practitioner sent on 10/26/21 a physician order for Foley Cather but due to SP#3 being admitted to the hospital on 10/27/21, the order was not completed. Telephone interview was conducted with SP#3’s caregiver on 11/12/21 between 11:22 am to 12:11 pm. The caregiver explained that the nurse practitioner stated visiting monthly after SP#3 was discharged from the hospital back in August. The caregiver stated that the nurse practitioner would assess the patient but did not assess the wound due to nurse practitioner being aware of home health agency providing daily wound care. The caregiver added that she requested from nurse practitioner to have a wound care specialist evaluate SP#3’s sacrum wound since it was being reported by visiting nurse that the wound was deteriorating. The nurse practitioner agreed to get a wound care specialist evaluate the wound when he last visited on Monday (10/25/21) but the patient required to be taken to the hospital because she was not feeling well on 10/27/21. Telephone interview was conducted on 11/12/21 between 12:41 pm to 1:12 pm with the Registered Nurse (RN) providing care to SP#3. The RN stated that she did not call the SP#3’s physician to notify of the wound status. The RN stated that she only informed the Case Manager, and she was the one to call the physician. The RN stated that Case Manager informed her that she called the physician’s office but would get no answer or she would be left on hold for long periods of time and therefore was never able to speak with someone at the physician’s office. The RN stated that she informed the SP#3’s daughter of the wound condition and told her to ask the physician for a wound care specialist.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to ensure the clinical record included 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 Home Health Agency (HHA) becomes aware of the transfer for 1 out 3 Sampled Patients (SP). (SP#3) Findings include: Record review of the clinical record for SP#3 revealed that on 08/11/21 a transfer to an inpatient facility was completed. The documentation revealed the patient was admitted to hospital [hospital name] due to low hemoglobin levels. A second transfer to an inpatient facility was completed on 10/26/21 and the documentation revealed the patient was admitted to hospital [hospital name] due to wound deterioration. Further review of the clinical record revealed no documentation of a transfer summary completed on 08/11/21 and 10/26/21 providing the receiving facility patient's current course of illness and treatment to ensure the safe and effective transition of care. Interview conducted with the Administrator and Director of Nursing (DON) on 11/12/21 between 4:29 pm and 4:49 pm. The Administrator reviewed the clinical record for SP#3 and stated that only the patient’s physician was notified of the transfer to hospital via a modified order. The Administrator acknowledges that no transfer summaries were conducted for 08/11/21 and 10/26/21 transfers to inpatient facility.

A Complaint Survey for complaint #2021009450 was conducted on August 09, 2021 at One At Home - Dade. The Home Health Agency was not compliance with 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to coordinate care delivery to meet the patient's needs for 1 out of 3 Sampled Patients (SP). SP#3 Clinical record review of SP#3 conducted on 08/09/21 revealed the patient was admitted on 06/28/21 and the Plan of Care reads for skilled nurse to be provided for evaluation and discharge; physical therapy 1wk1 (one time a week for one week), 3wk1 (three times a week for one week), 1wk1 (one time a week for one week); occupational therapy 1wk1 (one time a week for one week), 3wk1 (three times a week for one week), 1wk1 (one time a week for one week); speech therapy evaluation; and home health aide 2wk1 (twice a week for one week), 3wk1 (three times a week for one week). An updated physician order dated 07/10/21 revealed an extension of the speech therapy frequency of 3wk3 (three times a week for three weeks), 1wk1 (one time a week for one week) and home health aide frequency of 3wk3 (three times a week for three weeks), 1wk1 (one time a week for one week). Review of the clinical record revealed that speech therapy was provided effective 07/10/21 on 07/13/21, 07/15/21 and 07/20/21. Further review of the clinical record omitted reason for not providing the home health aide service effective 07/10/21. Interview conducted with the Director of Nursing (DON) on 08/09/21 at 1:28 pm stated that the case manager believes that due to the hassle of the requesting authorization for additional speech therapy visits, that it could be he forgot to re-schedule the home health aide and therefore the aide did not resume to provide the service after 07/10/21. At 2:13 pm Administrator and DON acknowledged that there was no additional order and/or communication in the system to cancel the home health aide service for SP#3, and that the speech therapist continued until 7/20/21.