Every finding on record at Presence Home Care

Recertification survey completed. Standard level deficiencies cited. SOC = Start of Care POC= Plan of Care SN = Skilled Nurse Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon, Evening COVID -19 = Corona Virus Disease 2019 PT = Physical Therapy/Therapist OT= Occupational Therapy/Therapist > = greater than < =less than GU = Genitourinary BS = Blood Sugar MD = Medical Doctor X = times PPE = Personal Protective Equipment

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 provide services and treatments as ordered by the Physician in the POC. This was found in 5 of 17 (Pts. #14, 17, 3, 11, and 15) clinical records reviewed. Findings include: 1. Pt. #14 SOC 9/9/21 Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 1/11/22 at 10:30 AM. The POC dated 9/9/21 required the PT to notify the physician of a temperature greater than 100.5. The PT weekly visit notes dated 9/13/21 (week #2) thru 10/20/21 (weeks #7) failed to include the assessment of the patient’s temperature and the POC was not modified. 2. Pt. #17 SOC 9/7/21 Primary Diagnosis: Other Chronic Pain. The clinical record was reviewed on 1/11/22 at 11:45 AM. The POC dated 9/7/21 required the OT to provide care 2 times a week for 2 weeks and 1 time a week for 4 weeks. The OT visits were not conducted the week of 9/28/21 (week #4) and the POC was not modified. 3. Pt. #3. SOC 12/22/21. Diagnoses: Urinary Tract Infection, Bladder Cancer with Urostomy. The clinical record was reviewed on 1/11/21 at 1:10 PM. The record contained the POC effective 12/22/21 to 2/19/22. This POC contained the Physician’s order: “…Assess GU status/identify complications. Assess skin integrity around stoma/instruct in site care. Instruct in care of ostomy/change of bags/stoma care…” The record also included SN visit notes dated 12/23/21, 12/30/21, and 1/3/22. These visit notes lacked documentation of the condition of the Patient’s skin integrity around the urostomy stoma site. The SN visit note dated 1/3/22 also lacked Pt./Caregiver instruction regarding urostomy stoma care and bag changing. 4. Pt. #11. SOC 12/24/21. Primary Diagnosis: Sepsis, Unspecified Organism. The clinical record was reviewed on 1/11/21 at 1:50 PM. The record included the POC effective 12/24/21 to 2/21/22, which contained the Physician’s order: “…Blood sugar parameters. Call MD if BS 300…” The record also contained the SN visit note dated 12/30/21. This note lacked documentation of the Patient’s blood sugar level. 5. Pt. #15. SOC 10/26/21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 1/11/22 at 2:40 PM. The record contained the POC effective 10/26/21 to 12/24/21. This POC included the Physician’s order: “…SN 10/26/21. 2 x week x 1 week…” The record lacked documentation of a second SN visit for the week of 10/26/21 to 10/30/21, as well as documentation the Physician was notified of this missed visit. 6. The Agency policy titled “Missed Visits” was reviewed on 1/12/22 at 10:50 AM. The policy required: “…Missed visits will be communicated to the Clinical Supervisor and the Patient’s Physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record…” 7. During interviews with the Director of Quality and Pt. Safety, the Clinical Team Supervisor, the Quality Specialist, and the Rehab Supervisor on 1/12/22 beginning at 11:15 AM to 1:10 PM, the above findings were confirmed.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. 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 Pts. are screened for COVID-19, prior to providing Pt. care and services. This was found in 13 of 17 (Pts. # 5, 6, 7, 10, 3, 11, 15, 12, 13, 17, 4, 8, and 9) clinical records reviewed. 11. Pt. #4. SOC 11/24/21. Primary Diagnosis: Sepsis due to Escherichia Coli. The clinical record was reviewed on 1/11/22 at 3:30 PM. The record contained the PT visit notes dated 12/20/21 and 12/22/21, indicating service was provided. The record lacked documentation the PT screened the Pt. for COVID-19 symptoms, prior to providing service as required by the Agency. 12. Pt. #8. SOC 12/16/21. Diagnoses: Encounter for Surgical Aftercare Following Surgery on the Circulatory System and COVID-19. The clinical record was reviewed on 1/10/22 at 2:00 PM. The record contained the OT visit note dated 1/7/22, indicating service was provided. The record lacked documentation the OT screened the Pt. for COVID-19 symptoms, prior to providing service. 13. Pt. #9. SOC 11/24/21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 1/12/22 at 9:20 AM. The record contained the SN visit notes dated 12/3/21, 12/7/21, 12/28/21 and 1/8/22; PT visit notes dated 12/3/21, 12/7/21, 12/13/21 and 12/17/21; and OT visit notes dated 12/3/21, 12/6/21, 12/10/21, 12/15/21, 12/16/21 and 12/20/21 indicating service was provided. The record lacked documentation the SN, PT and OT screened the Pt. for COVID-19 symptoms, prior to providing service on the days indicated above. 14. The Agency’s policy titled, “COVID-19 Screening...Documentation Protocol” was reviewed on 1/12/22 at 2:50 PM. The policy required: “…2. All Home Care clinicians will screen by calling the patient prior to each home visit... 6. If there are no Clinical Symptoms, Screen is Negative... 10. If Screen is Positive, complete the same COVID-19 Screening Tool…” 15. During an interview with the Director of Operations on 1/12/22 at 12:55 PM, the Director stated: For patients admitted to the Agency with a COVID-19 diagnosis, initially no COVID screening is required, all staff are required to wear "full PPE" for the first 7 days when entering the patient’s residence. After the first 7 days, staff are required to perform COVID screening prior to each visit on the day before the visit, or day of the visit prior to arriving at the patient’s residence, and this information is entered into the clinical record. 16. During an interview with the Clinical Team Supervisor on 1/12/22 at 3:08 PM, the Clinical Team Supervisor stated "full PPE" consists of: Disposable hair covers, gloves, heavy duty shoe covers, gowns, surgical masks, N-95 respirators, face shield, biohazard bag and a paper bag. 17. During an interview with the Director of Operations, Clinical Team Supervisor, Director of Quality and Pt. Safety, Quality Specialist and the Rehabilitation Supervisor on 1/12/22 at 11:15 AM to 1:10 PM, the Director of Operations and the Clinical Team Supervisor confirmed staff failed to screen Pts. for COVID-19 symptoms as indicated above. 8. Pt. #12 SOC 12/7/21 Primary Diagnosis: Post Thrombotic Syndrome with Ulcer and Inflammation of Right lower Extremity. The clinical record was reviewed on 1/11/22 at 9:30 AM. The SN visit notes dated 12/20/21 (week #3) thru 12/29/21 (week #4) lacked documentation the SN screened the Pt./family for COVID-19 symptoms, before providing care/service as required by the Agency. 9. Pt. #13 SOC 9/16/21 Primary Diagnoses: COVID-19 and Pneumonia due to Coronavirus Disease 2019. The clinical record was reviewed on 01/11/22 at 10:00 AM. The weekly SN visit notes dated 9/21/21(week #2) thru 10/20/21(week #6) and the weekly OT visit notes dated 9/20/21 (week #2) thru 10/29/21(weeks #7) lacked documentation the staff screened the Pt./family for COVID-19 symptoms, before providing care/service as required by the Agency. 10. Pt. #17 SOC 9/07/21 Primary Diagnosis: Other Chronic Pain. The clinical record was reviewed on 1/11/22 at 11:45 AM. The OT visit notes dated 10/13/21 (week #6) and 10/19/21 (weeks #7) lacked documentation the OT screened the Pt./family for COVID-19 symptoms, before providing care/service as required by the Agency. Findings include: 1. Pt #5. SOC 12/28/21. Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 1/11/22 at 8:00 AM. The record lacked documentation the SN screened Pt. for symptoms of COVID-19, prior to the visit on 12/28/21, for PT on 12/30/21 and for OT on 12/29/21. 2. Pt #6. SOC 1/7/22. Diagnosis: Sepsis. The clinical record was reviewed on 1/11/22 at 9:00 AM. The record lacked documentation the OT screened Pt. for signs and symptoms of COVID-19, prior to the visit on 1/7/22. 3. Pt #7. SOC 12/22/21. Diagnosis: Metabolic Encephalopathy. The clinical record was reviewed on 1/11/22 at 3:00 PM. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19, prior to the visits on 12/22/21 and 1/5/22, PT on 12/29/21 and OT on 12/27/21, 12/29/21 and1/3/22. 4. Pt #10. SOC 1/3/22. Diagnosis: Covid-19. The clinical record was reviewed on 1/12/22 at 9:30 AM. The record lacked documentation the PT screened the Pt. for symptoms of COVID-19, prior to the visit on 1/3/22. 5. Pt. #3. SOC 12/22/21. Primary Diagnosis: Urinary Tract Infection, Bladder Cancer with Urostomy. The clinical record was reviewed on 1/11/22 at 1:10 PM. The record included documentation the SN provided service on 1/3/22. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to this visit. The record also contained documentation the OT provided service on 12/28/21 and 12/30/21. The record lacked documentation the OT screened the Pt. for symptoms of COVID-19 prior to these visits. 6. Pt. #11. SOC 12/24/21. Primary Diagnosis: Sepsis, Unspecified Organism. The clinical record was reviewed on 1/11/22 at 1:50 PM. The record included documentation the SN provided service on 12/24/21, 12/27/21, and 12/30/21. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to these visits. 7. Pt. #15. SOC 10/26/21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 1/11/22 at 2:40 PM. The record included documentation the SN provided service on 11/18/21, and 11/23/21. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to these visits. The record also contained documentation the OT provided service on 11/4/21. The record lacked documentation the OT screened the Pt. for symptoms of COVID-19 prior to this visit.