Every finding on record at Oracle Healthcare Inc

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on the review of the Agency's Emergency Preparedness Plan, policy review, and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 11/30/22 at 10:15 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members and Patients' Physicians. 2. The Agency policy titled, “Emergency Preparedness Plan" was reviewed on 11/30/22 at 11:00 AM. The policy required: "The communication plan includes all of the following: (1) Names and contact information of the following (i) Staff (iii) Patients’ physicians…” 3. During an interview with the Administrator and Director of Nursing on 11/30/22 at 3:00 PM, the above finding was confirmed.

Recertification survey was conducted. Standard level deficiencies cited. Abbreviations: Pt./ Pts. = Patient/Patients AM = morning PM = afternoon/evening SOC = Start of care SN = Skilled Nurse RN = Registered Nurse PsOC = Plans of care POC = Plan of care HIPAA = Health Insurance Portability and Accountability Act

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: A. Based on review of clinical records, and staff interviews, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 4 of 7 (Pts. #5, 6, 1 and 2) clinical records reviewed. 3. Pt. #1. SOC 10/5/22. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/30/22 at 11:40 AM. As of 12/1/22 at 9:30 AM, the record contained the form titled, "Referral" which lacked a date. The record also contained the form titled, "Face to Face Encounter Form” which included documentation of a physician visit dated 9/28/22 and required SN visits. The Initial comprehensive assessment was conducted by the RN on 10/5/22, which was 7 days after the physician encounter. The record lacked documentation of the Agency started care/services within 48 hours of the referral date. 4. Pt. #2. SOC 9/29/22. Principal Diagnosis: Hypertensive Heart and Chronic Kidney Disease With Heart Failure Stage 1-4 Unspecified Kidney Disease. The clinical record was reviewed on 11/30/22 at 10:30 AM. The record contained the form titled, "Referral" which included the date of 9/8/22. The record also contained the form titled, "Encounter Tele-Medicine…” which included documentation of a physician “Date of Service 9/6/22” and required SN visits. The Initial comprehensive assessment was conducted by the RN on 9/29/22, which was 23 days after the physician encounter. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 5. During an interview with the Administrator and the Director of Nursing on 11/30/22 at 2:15 PM to 3:30 PM, the above findings were confirmed. Findings include: 1. Pt. #5. SOC 8/9/22. Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/29/22 at 10:15 AM. The record included the SOC comprehensive assessment form completed by the SN and dated 8/9/22, 5 days after the Face to Face was completed by the Physician. The record/Agency lacked a referral to initiate service. The Face-to-Face form requiring "Skilled Nursing 2 x/1week and 1xweek for 8 weeks” was signed by the Physician and dated 8/4/22. The record lacked documentation the Pt. was discharged from an inpatient facility or there was a Physician ordered SOC date. As of 12/1/22, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #6. SOC 10/4/22. Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/29/22 at 11:15 AM. The record included the SOC comprehensive assessment form completed by the SN and dated 10/4/22, 14 days after the Face to Face was completed by Physician. The record/Agency lacked a referral to initiate service. The Face-to-Face form requiring "Skilled Nursing 1 x/week for 9 weeks" was signed by the Physician and dated 9/20/22. The record lacked documentation the Pt. was discharged from an inpatient facility or there was a Physician ordered SOC date. As of 12/1/22, the record lacked documentation the Agency initiated service within the required time frame.

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: A. Based on clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure the physician reviewed and signed the PsOC. This was found in 2 of 7 (Pts. #2 and 5) clinical records reviewed. 2. Pt. #5. SOC 8/9/22. Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/29/22 at 10:15 AM. The record included the POC dated 8/9/22 to 10/7/22 that lacked physician’s signature as of today 11/1/22. 3. The Agency's policy titled, "Physicians/Practitioners Orders" was reviewed on 11/30/22 at 2:00 PM and included: "...19. The total Plan of Care will be reviewed and signed by the attending physician/practitioner and Agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least one every sixty (60) days. 4. During an interview with the Administrator and Director of Nursing on 11/30/22 between 2:15 PM to 3:30 PM, the Administrative team confirmed the above findings. Findings include: 1. Pt. #2. SOC: 9/29/22. Principal Diagnosis: Hypertensive Heart and Chronic Kidney Disease With Heart Failure Stage 1-4, Unspecified Kidney Disease. The clinical record was reviewed on 11/30/22 at 10:30 AM. As of 11/30/22, the POC dated 9/29/22 to 11/27/22 lacked physician's signature, verifying the physician reviewed and approved the POC. As of 11/30/22, Pt. #2 is actively receiving services.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interviews, it was determined the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. This was found in 4 of 7 (Pts. #1, 3, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 11/29/22 to 11/30/22 from 9:15 AM to 11:40 AM. Pt. #1. SOC 10/05/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry Pt. #3. SOC 11/07/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry Pt. #6. SOC 10/04/22. Lacked an Influenza and Pneumococcal Pneumonia inquiry Pt. #7. SOC 09/30/21. Lacked an Influenza and Pneumococcal Pneumonia inquiry. 2. During an interview with the Administrator and the Director of Nursing on 11/30/22 from 2:15 PM to 3:30 PM, the Director of Nursing stated, the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in SOC comprehensive assessment and or the Flu/Pneumonia Vaccine Questionnaire upon admission. During the same interview, the Director of Nursing confirmed the SOC comprehensive assessment/clinical record lacked an inquiry for the Pneumococcal Pneumonia and Influenza vaccines.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interviews, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6, and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 10/4/22. Diagnosis: Primary Essential Hypertension. The closed/discharge clinical record was reviewed on 11/30/22 at 11:15 PM. The record/Agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #6 was discharged on 11/9/22. 2. Pt. #7. SOC 9/30/21. Diagnosis: Pressure Ulcer Right and Left Buttock, stage II. The closed/discharged clinical record was reviewed on 11/30/22 at 12:15 PM. The record/Agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #7 was discharged on 11/27/21. 3. During an interview with the Administrator and Director of Nursing on 11/30/22 between 2:15 PM to 3:30 PM, the Administrator confirmed the Agency failed to send the Discharge Summary sent to the attending Physician.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 6 of 7 (Pts. #1, 2, 3, 4, 5 and 6) clinical record reviewed. Findings include: 1. The following clinical records were reviewed on 11/29/22 at 9:15 AM to 11/30/22 at 11:40 AM: Pt. #1. SOC: 10/5/22 Pt. #2. SOC: 9/29/22 Pt. #3. SOC: 11/7/22 Pt. #4. SOC: 10/26/22 Pt. #5. SOC: 8/9/22 Pt. #6. SOC: 10/4/22 The records contained a form “HIPAA Privacy Authorization Form” that at the SOC, the Pt./patient's representative participated had to complete. The forms were only signed and dated by the Pt., but areas of the form that were to be filled out were left blank. 2. The policy titled, “Medical Record Entries and Authentication” was reviewed on 11/30/22 at 12:00 PM and required: “All entries in Pt. records will be legible, clear, complete and appropriately authenticated, dated and timed…” 3. During an interview with the Administrator and Director of Nursing on 11/30/22 at 2:15 PM to 3:30 PM, the above findings were confirmed.