Every finding on record at Priority Care, Inc

E Tag 000 Unannounced visits were concluded at Patient Care Rocky Hill on 4/25/24 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

G Tag 000 Unannounced visits concluded at Patient Care Rocky Hill, Inc on 4/25/24 for the purpose of recertification. Standard Level of deficiencies were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interview with agency personnel, for one of one patient (Patient #2) with a diagnosis of congestive heart failure requiring weight monitoring, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs. Patient #2 had a start of care date of 2/04/23 and diagnoses that included heart failure, type II diabetes mellitus and hypertension. The physician's orders for the certification periods of 1/30/24 through 5/28/24 included nursing services once weekly for medication pre-pour, diabetic and cardiac assessments. Interview and review of the physician’s certified plan of care with the Administrator on 4/25/24 at 10 AM failed to identify communication with the physician for the need to monitor weights and parameters for reporting abnormal findings to the physician. Review of the agency policy for Plan of Care directed that the plan of care includes patient specific interventions and education, measurable outcomes and goals identified by the agency and patient.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review and interviews with agency personnel for one of eight patients (Patient #9), requiring medication management, the agency licensed personnel failed to follow agency expectations for medication documentation in the electronic clinical record. The findings include: Patient #9 had a start of care date of 11/16/23 and diagnoses that included chronic pain syndrome and post laminectomy syndrome. The physician’s orders for the certification periods of 1/15/24 through 5/13/24 included nursing services daily for pain assessment, medication administration of morning medications, and pre-pouring of the afternoon and evening medications. Patient #9’s medications included Belbuca Buccal film (an opioid analgesic controlled substance) 900 micrograms/mcg twice daily for pain, Gabapentin 800 milligrams/mg three times a day for pain and Tizanidine Hydrochloride 2 mg every eight hours for muscle spasms. Interview and review of LPN #1’s nursing notes dated 3/02/24, 3/04/24, 3/09/24, 3/10/24, 3/23/24 and 3/24/24 with the Administrator on 4/25/24 at 11 AM identified documentation of the Controlled Substance count of the Belbuca film administered and pre-poured daily, but failed to identify documentation of the medications administered and pre-poured during the nursing visit according to agency expectations.

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 reviews, review of an agency policies and interview with agency staff, for one of five patients (Patient #6) who required nursing assessments and blood glucose monitoring, the agency failed to perform the necessary assessments in accordance with the agency’s expectation and policy. The findings include: a. Patient #6 had a start of care date 04/08/2022 with diagnosis that included high blood pressure, type II diabetes and acid reflux. The physician’s orders for the certification periods of 01/28/2024 to 03/27/2024 included nursing services once per week for nursing assessments, weekly pre-pour of medications, assess the Patient’s diabetic status and review the Patient’s blood glucose log. i. Interview and review of Patient #6’s nursing notes with the Administrator on 04/25/2024 at 11:30 AM, failed to identify blood glucose levels were assessed and documented on 01/31/2024, 03/06/2024, 03/13/2024 and 03/27/2024. The Administrator indicated the agency's expectation was to assess and document blood glucose levels at each nursing visit, to assess the Patient’s condition, and and the patient's response to the medication and diabetic education. Review of the agency’s Patient Assessment, Initial and Reassessment policy, identified a patient’s status would be reviewed as an ongoing process. Patients are assessed for continued need and response to care and services.

Unannounced visit concluded on May 17, 2023, at Patient Care in Rocky Hill for the purpose of a complaint investigation. Standard-level deficiencies were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of three patients (Patient #1) in the survey sample, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs. The findings include: Patient #2 had a start of care date of 5/07/21 and diagnoses that included calculus of the kidney and psoriasis. The physician's orders for the certification period of 4/27/23 to 6/25/23 included nursing services weekly for pre-pouring of morning and evening medications, administration of Enbrel 50 mg/ml (milligrams/milliliter) subcutaneously weekly and assessments. Interview and review of the weekly nursing notes from 4/28/23 through 5/12/23 with the Supervisor of Clinical Services/SCS on 5/17/23 at 1 PM identified the weekly administration of Enbrel, but failed to identify the weekly pre-pouring of the patient’s medications. Subsequent interview and review of the plan of care with the SCS identified that the patient manages his/her own medications and has for years and failed to ensure a comprehensive care plan addressed the patient’s needs.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of three patients (Patient #1) requiring medication management, the agency nurses failed to follow agency policies. The findings include: Patient #1 had a start of care date of 1/10/12 and diagnoses that included schizoaffective disorder, hypertension, and type II diabetes mellitus. The physician's orders for the certification periods of 3/13/23 to 7/10/23 included nursing services weekly for pre-pouring morning and evening medications and assessments of diabetic status. Physician’s orders directed to pre-pour Lorazepam (a Schedule IV controlled substance) 0.5 mg once a day in the morning and Lorazepam 0.5 mg, 2 tablets at bedtime for anxiety. Interview and review of LPN #1’s weekly nursing notes from 3/23/23 to 5/11/23 with the SCS on 5/17/23 at 1:20 PM identified that Lorazepam was pre-poured weekly, but failed to identify a controlled substance record was initiated as a mechanism for counting the number of tablets of Lorazepam found in the bottle, and the remaining balance of the tablets after the nurse accessed the controlled substance and failed to follow agency policies. Review of agency documentation identified that the SCS received a call on 5/1/23 from Patient #1’s caregiver identifying that the wrong medication, Keppra was pre-poured into the medication crutch, recently the medication was changed to Depakote but both medications were picked up from the pharmacy and the Keppra was pre-poured instead of the Depakote. Interview and review of the agency investigation with the SCS on 5/17/23 at 10:10 AM identified that on 3/30/23, LPN #1’s nursing note indicated that the physician discontinued Keppra and started patient on Depakote Sodium Delayed Release/DR 500 mg twice daily. On 4/27/23, LPN #1 picked up both the Keppra (which the pharmacy was not aware had not be discontinued) and the new medication Depakote, and inadvertently pre-poured the discontinued Keppra (twice daily) for the week of 4/27/23, evening dose, through 5/2/23 morning dose (10 doses), instead of the Depakote (only) twice daily pre-pour. After being alerted by the caregiver of the incorrect medication (Keppra) pre-poured, LPN #1's nursing note dated 5/2/23 identified that the Keppra was removed from the medication crutch and Depakote 500 mg was pre-poured for the additional three days left in the medication crutch, and LPN #1 failed to follow agency policies for medication preparation including observing the “five rights” when preparing medications and reading the label three times. Review of agency policies for Medication Administration directed in part that for patients with medications considered to be controlled substances, the clinician will maintain a controlled substance record and count medications with the oncoming nurse at shift change or with the patient or family. The nurse will observe the “five rights” when administering or preparing medications and the label on the container must be read at three intervals; (1) when it is taken from the storage area (2) when dispensing the medication (3) before returning it to the storage area.

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 clinical record review and interview with agency personnel, for one of three patients (Patient #1) who required medication management, the agency nurses failed to ensure the care delivered was in accordance with the physician's orders. The findings include: Patient #1 had a start of care date of 1/10/12 and diagnoses that included schizoaffective disorder, hypertension, and type II diabetes mellitus. The physician's orders for the certification periods of 3/13/23 to 7/10/23 included nursing services weekly for pre-pouring morning and evening medications and assessments of diabetic status. Physician’s orders dated 3/30/23, directed to pre-pour Depakote Sodium Delayed Release/DR 500 mg twice daily. Interview and review of LPN #1’s nursing note dated 4/06/23 with the SCS on 5/17/23 at 11:500 AM failed to identify the weekly pre-pouring of Depakote twice daily and failed to follow physician’s orders. Subsequent interview with LPN #1 on 5/17/23 at 12:10 PM, indicated that s/he recalls pre-pouring the Depakote on 4/06/23 for the week, but may have been distracted, and forgot to click on the medication in the tablet to identify that the Depakote was pre-poured for one week.

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 review of the clinical record, interview with agency personnel and review of agency policies, for one of three patients (Patient #1) in the survey sample, the agency nurses failed to communicate with the physician involved in the plan of care. The findings include: Patient #1 had a start of care date of 1/10/12 and diagnoses that included schizoaffective disorder, hypertension, and type II diabetes mellitus. The physician's orders for the certification periods of 3/13/23 to 7/10/23 included nursing services weekly for pre-pouring morning and evening medications and assessments of diabetic status. Review of agency documentation identified that the SCS received a call on 5/1/23 from Patient #1’s caregiver identifying that the wrong medication, Keppra was pre-poured into the medication crutch. Recently the medication was changed to Depakote, but both medications were picked up from the pharmacy at the same time and the Keppra was pre-poured instead of the new Depakote medication. Interview and review of the agency investigation with the SCS on 5/17/23 at 10:10 AM identified that on 3/30/23, LPN #1’s nursing note indicated that the physician discontinued Keppra and started Depakote Sodium Delayed Release/DR 500 mg twice daily. On 4/27/23, LPN #1 picked up both the Keppra (which the pharmacy was not aware had not be discontinued) and the Depakote which was dispensed by the pharmacy, and inadvertently pre-poured the Keppra twice daily for the week of 4/27/23 evening dose through 5/2/23 morning dose (10 doses), instead of the Depakote twice daily. After being alerted by the caregiver of the incorrect medication (Keppra) was pre-poured, LPN #1 was instructed by the SCS to call the physician concerning the medication error. On 5/8/23, subsequent to the medication pre-pour, the caregiver called the physician after the patient had two seizures on 5/6/23, to see if there were any new orders or a change in seizure medication, and was advised that the physician’s office never received a call from LPN #1, regarding the incorrect medication pre-pour. Interview with LPN #1 on 5/17/23 at 12 noon indicated that s/he left a message at the office concerning the medication error but never called back. Interview with the SCS on 5/17/23 at 12:40 PM identified that LPN #1 should have called back the physician to follow up on any new orders from the medication error and failed to follow agency policies. Review of agency policies for Medication Errors directed in part to contact the patient’s physician immediately and follow appropriate physician orders.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel for two of three patients (Patient #1 & 2), the Clinical Manager failed to ensure the development, implementation and updates of the individualized plan of care. The findings include: a. Patient #1 had a start of care date of 1/10/12 and diagnoses that included schizoaffective disorder, hypertension, and type II diabetes mellitus. The physician's orders for the certification periods of 3/13/23 to 7/10/23 included nursing services weekly for pre-pouring morning and evening medications and assessments of diabetic status. Physician’s orders directed to pre-pour Lorazepam (a Schedule IV controlled substance) 0.5 mg once a day in the morning and Lorazepam 0.5 mg, 2 tablets at bedtime for anxiety. Interview and review of LPN #1’s weekly nursing notes from 3/23/23 to 5/11/23 with the SCS on 5/17/23 at 1:20 PM identified that Lorazepam was pre-poured weekly but failed to identify a controlled substance record was initiated as a mechanism for counting the number of tablets of Lorazepam found in the bottle, and the remaining balance of the tablets after the nurse accessed the controlled substance and failed to ensure oversight by the clinical manager in reviewing individual records of patient’s with pre-pouring of controlled substances according to violation letter dated 1/3/23. b. Patient #2 had a start of care date of 5/07/21 and diagnoses that included calculus of the kidney and psoriasis. The physician's orders for the certification period of 4/27/23 to 6/25/23 included nursing services weekly for pre-pouring of morning and evening medications, administration of Enbrel 50 mg/ml (milligrams/milliliter) subcutaneously weekly and assessments. Interview and review of the weekly nursing notes from 4/28/23 through 5/12/23 with the Supervisor of Clinical Services/SCS on 5/17/23 at 1 PM identified the weekly administration of Enbrel but failed to identify the weekly pre-pouring of the patient’s medications. Subsequent interview and review of the plan of care with the SCS identified that the patient manages his/her own medications and has for years and failed to ensure oversight of development and update of the plan of care.

Unannounced visit was concluded at Patient Care Home Health agency - Rocky Hill CT on 12/19/22 for the purpose of a complaint investigation survey numbered CT # 94572. Standard level deficiencies were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interview, with agency personnel, for three of six patients (Patient’s #1, 2 & 5) in the survey sample, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs. The finding includes: 1. Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Review of the nursing notes from 8/13/22 to 8/22/22 identified daily medication administration of morning medications and the pre-pouring of the evening and bedtime medications. Interview and review of the plan of care dated 6/26/22 with the Administrator on 12/19/22 at 1:20 PM failed to identify the development of a comprehensive care plan that included the pre-pouring of the evening and bedtime medications. 2. Patient #2 had a start of care date of 8/14/13 and diagnoses that included intellectual disabilities and hypertension. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services three times a week for medication administration, health assessments and home health aide services four times weekly for medication queuing/prompting. Interview and review of the plan of care dated 6/28/22 with the Administrator on 12/19/22 at 1:25 PM failed to identify the development of a comprehensive care plan that included the weekly pre-pouring of the morning medications four times a week and the evening and bedtime medications. 3. Patient #5 had a start of care date of 12/31/21 and diagnoses that included type II diabetes mellitus and bipolar disorder. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services one time a week for medication administration and assessments. Interview and review of the plan of care dated 6/28/22 with the Administrator on 12/19/22 at 2 PM failed to identify the development of a comprehensive care plan that included frequency of blood glucose monitoring and specific parameters for reporting abnormal blood glucose results to the physician. Review of the nursing notes from 6/29/22 to 8/26/22 identified daily nursing visits for medication administration of morning medications and pre-pouring of bedtime medications. Interview and review of the plan of care dated 6/28/22 with the Administrator on 12/19/22 at 2 PM failed to identify the development of a comprehensive care plan that included nursing visits seven times a week (plan of care frequency indicated once a week nursing visits) for medication administration and pre-pouring of bedtime medications

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for three of three patients (Patient #1, 2 & 5) in the survey sample, the agency licensed personnel failed to follow agency policies. The finding includes: 1.Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Interview and review of LPN #1’s nursing notes dated 8/15/22, 8/18/22, 8/19/22 and 8/22/22 with the Administrator on 12/19/22 at 1 PM identified a morning visit for medication administration, but failed to identify the medications and doses administered were documented in the visit note according to agency policy. 2.Patient #2 had a start of care date of 8/14/13 and diagnoses that included intellectual disabilities and hypertension. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services three times a week for medication administration and assessments and home health aide services four times weekly for medication prompting. Interview and review of the nursing note dated 8/23/22 with the Administrator on 12/19/22 at 1:25 PM failed to identify the pre-poured medications and doses documented in the visit note according to agency policy. 3.Patient #5 had a start of care date of 12/31/21 and diagnoses that included type II diabetes mellitus and bipolar disorder. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services seven times a week for medication administration and assessments. Interview and review of LPN #2’s nursing notes dated 8/21/22, 8/22/22 and 8/26/22 with the Administrator on 12/19/22 at 1:30 PM failed to identify the medication and doses administered and pre-poured medications and doses documented in the visit note according to agency policy. Review of the agency policy for medication administration directed, to document medication administration entries which must be entered via the “Medication Profile” button in the visit/form. Only medication administration entries made from the medication profile button in a visit/form will populate to the visit note. Physician’s orders directed to administer Klonopin (a Schedule IV controlled substance) 0.5 milligrams/mg twice a day as needed for anxiety. Interview and review of the clinical record from 6/26/22 to 8/24/22 with the Administrator on 12/19/22 at 1 PM identified that Klonopin was administered and pre-poured daily, but failed to identify a mechanism for the number of tablets of Klonopin found in the bottle, and the remaining balance of the tablets after the nurse accessed the controlled substance. Review of agency policy for medication management directed to count narcotics with oncoming nurse at shift change and document findings, including staff initial and date and time of count.

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 review of the clinical record and interview with agency personnel, for one of seven patients (Patient #1) in the survey sample, the agency nurses failed to provide the necessary assessments. The finding includes: 1 Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Interview and review of the nursing notes from 8/13/22 to 8/22/22 with the Administrator on 12/19/22 at 1:20 PM failed to identify documentation of blood sugar results.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of six patients (Patient #1) in the survey sample, the agency Registered Nurses (RN) failed to ensure monthly supervision of the Licensed Practical Nurses (LPN) in accordance with the agency policy. The finding includes: Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Interview and review of the nursing notes from 6/27/22 to 8/24/22 (8 weeks) with the Administrator on 12/19/22 at 12:30 PM identified that the daily medication administration visits were completed by LPN's, but failed to identify monthly supervision of the LPN's documented by the RN in the clinical record. Review of agency policy for LPN supervision with the Administrator indicated that LPN supervisions should be documented in the clinical record on a monthly basis.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on clinical record review and interview with agency personnel for one of one patient (Patient #1), requiring administration of a controlled substance, the Governing Body failed to develop policies and procedures for the management of the administration and pre-pouring of controlled substances to identify misuse or discrepancies by agency personnel. The finding includes: Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Physician’s orders directed to administer Klonopin (a Schedule IV controlled substance) 0.5 milligrams/mg twice a day as needed for anxiety. Interview and review of the clinical record from 6/26/22 to 8/24/22 with the Administrator on 12/19/22 at 1 PM identified that Klonopin was administered and pre-poured daily, but failed to identify a mechanism for the amount of tablets of Klonopin found in the bottle, and the remaining balance of the tablets after the nurse accessed the controlled substance, and failed to identify documentation policies to ensure the safety and accuracy of controlled substances belonging to the patient and accessed by the nurse.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on clinical record review and interview with agency personnel for three of six patients (Patient’s #1, 2 and 5), who required recertification for home care services, the Clinical Manager failed to ensure an individualized plan of care to meet the patient’s needs. The finding includes: 1. Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Review of the nursing notes from 8/13/22 to 8/22/22 identified daily medication administration of morning medications and the pre-pouring of the evening and bedtime medications. Interview and review of the plan of care dated 6/26/22 with the Clinical Manager on 12/19/22 at 3:10 PM failed to identify the development of a comprehensive care plan that included the pre-pouring of the evening and bedtime medications. 2. Patient #2 had a start of care date of 8/14/13 and diagnoses that included intellectual disabilities and hypertension. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services three times a week for medication administration and assessments and home health aide services four times weekly for medication prompting. Interview and review of the plan of care dated 6/28/22 with the Clinical Manager on 12/19/22 at 3:10 PM, failed to identify the development of a comprehensive care plan that included the weekly pre-pouring of the morning medications four times a week and the evening and bedtime medications. 3. Patient #5 had a start of care date of 12/31/21 and diagnoses that included type II diabetes mellitus and bipolar disorder. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services one time a week for medication administration and assessments. Interview and review of the plan of care dated 6/28/22 with the Clinical Manager on 12/19/22 at 3:10 PM failed to identify the development of a comprehensive care plan that included frequency of blood glucose monitoring and specific parameters for reporting abnormal blood glucose results to the physician. Review of the nursing notes from 6/29/22 to 8/26/22 identified daily nursing visits for medication administration of morning medications and pre-pouring of bedtime medications. Interview and review of the plan of care dated 6/28/22 with the Clinical Manager on 12/19/22 at 3:10 PM, failed to identify the development of a comprehensive care plan that included nursing visits seven times a week (plan of care frequency indicated once a week nursing visits) for medication administration and pre-pouring of bedtime medications.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of the clinical record and staff interview, for five of six patients (Patient’s #1, 2, 3, 4 & 5), the agency licensed personnel failed to follow agency policies and the agency failed to ensure accuracy and authenticity of the documentation. The finding includes: 1. Patient #1 had a start of care date of 4/27/22 and diagnoses that included bipolar disorder and type II diabetes mellitus. The physician's orders for the certification period of 6/26/22 to 8/24/22 included nursing services seven times a week for medication administration, assessments of diabetic status and patient/caregiver checking fasting/random blood sugars. Review of agency documentation on 12/19/22 at 9:30 AM with the Administrator identified a complaint received by the scheduler on 8/24/22 at 6:29 PM from Patient #1 indicating a nurse never visited that day to give the medications. Review of the clinical record identified that RN #1 punched in and out for a re-certification visit on 8/24/22 and review of the Global Positioning System/GPS coordinates identified that GPS was enabled for a punch in time of 9:25 AM (with coordinates consistent with RN #1’s home address) and disabled for a punch out time. Additional documentation identified that the Supervisor of Clinical Services/SCS #1 conducted and on-site visit to Patient #1 that evening and identified that the sleeve for Wednesday, 8/24/22 medications were still in the lock box. The SCS administered the prescribed, due medications and completed the assessment. Subsequently, a complete investigation of RN #1’s caseload identified the week of 8/22/22 to 8/25/22 inaccurate re-certification visit documentation for Patient’s #2, 3, 4, 5 & 6 and interviews with the above patients who confirmed that RN #1 never showed up for the visit that week. GPS tracking on RN #1’s computer was accessed, and it was identified that the visits to Patient’s #1, 2, 3, 4, 5 & 6 were clocked in from the same address which was RN #1’s home address. RN #1 was removed from all cases on 8/26/22 pending a complete investigation. 2. Patient #2 had a start of care date of 8/14/13 and diagnoses that included intellectual disabilities and hypertension. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services three times a week for medication administration and assessments and home health aide services four times weekly for medication prompting. Interview and review of RN #1’s 8/23/22 from 2:13 PM – 3:18 PM visit documentation with the Administrator on 12/19/22 at 10 AM identified incomplete re-certification assessment documentation and review of the GPS coordinates identified that GPS was disabled and there was only a punch in time of 2:34 PM. 3. Patient #3 had a start of care date of 5/22/18 and diagnoses that included anxiety disorder, cerebral infarction, and chronic obstructive pulmonary disease. The physician's orders for the certification period of 6/30/22 to 8/28/22 included nursing services weekly for assessments. Interview and review of RN #1’s 8/25/22 from 12:05 AM – 12:06 AM visit documentation with the Administrator on 12/19/22 at 10:10 AM identified incomplete re-certification assessment documentation and review of the punch in and punch out GPS coordinates identified the address of RN #1. 4. Patient #4 had a start of care date of 12/31/21 and diagnoses that included type II diabetes mellitus and bipolar disorder. The physician's orders for the certification period of 6/29/22 to 8/27/22 included nursing services seven times a week for insulin administration and assessments. Interview and review of RN #1’s 8/25/22 from 12:11 AM – 12:12 AM visit documentation with the Administrator on 12/19/22 at 10:15 AM identified incomplete re-certification assessment documentation and review of the punch in and punch out GPS coordinates identified the address of RN #1. 5. Patient #5 had a start of care date of 12/31/21 and diagnoses that included type II diabetes mellitus and bipolar disorder. The physician's orders for the certification period of 6/28/22 to 8/26/22 included nursing services seven times a week for medication administration and assessments. Interview and review of RN #1’s 8/25/22 from 10 PM – 11 PM visit documentation with the Administrator on 12/19/22 at 10:20 AM identified incomplete re-certification assessment documentation and review of the punch in and punch out GPS coordinates identified the address of RN #1. Review of agency policy on fraud, waste and abuse directed the responsibility of all employees to immediately report suspected fraud which includes falsifying documents to show services provided when no services were actually provided. Review of agency policy for information management directed that all entries in the home care record must be legible and accurate. Interview and review of the agency investigation with the Administrator on 12/19/22 at 2 PM identified that a meeting was conducted with the Administrator, Director of Clinical Services and RN #1 on 8/30/22, RN #1 indicated that she made on-site visits to Patient’s #1-6 and failed to follow agency policies in ensuring an authentic record. RN #1 was terminated on 8/30/22 for violation of standards of behavior and company policies and procedures. Interview with RN #1 on 12/19/22 at 11:20 AM indicated that he/she saw Patient’s #1-6 for re-certification visits, indicated that it was him/her word and paperwork against theirs and that he/she poured medications for Patient #1 and did not administer them from the Wednesday sleeve because he/she wasn’t the nurse that pre-poured them. Additionally, RN #1 indicated that Patient #1 was in a hurry to leave the house and must have forgotten that he/she had visited.

Unannounced visits concluded at Patient Care on 11/22/2021 for the purpose of investigating CT #61082 and CT#61245. The provider was out of compliance with the following Conditions of Participation: 42 CFR 484.55 Comprehensive assessment of patients G 510 Refer to G 544, 546 and 548 42 CFR 484.58 Care planning, coordination of services, and quality of care G 570. Refer to G 588 42 CFR 484.75 Skilled professional services G 700 Refer to G 702, 710, 718 42 CFR 484.105 Organization and administration of services G 940 Refer to G 942, 948, 958, 1024 Standard level deficiencies were also identified.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review, interviews, and review of agency policies, for one of six patients (Patient #1) in the survey sample, the agency clinical manager failed to document a complaint and its resolution. The finding includes: 1. Patient #1 had a start of care date of 3/22/21 and diagnoses that included hypertension, asthma and depression. The physician's orders for the certification period of 9/18/21 through 11/16/21 included nursing services one time a week for weekly medication pre-pouring and general assessments. a. Interview with Person #1 on 11/19/21 at 10:20 AM indicated that s/he called the agency notifying them that Patient #1 was found deceased in the apartment on 10/11/21. Person #1 indicated that three nurses went to visit the patient the week of 10/03/21 to 10/09/21, didn’t find the patient at home and was concerned that the Police Department was not notified to perform a wellness check. b. Interview with Clinical Manager #2 on 11/19/21 at 10:40 AM indicated that the morning of 10/11/21, s/he received a call from Person #1 that the patient was found deceased in the apartment, indicated that there were two missed visits the week before by LPN #1 and identified that LPN #1 should have followed up the next day with a visit but failed to document the call from Person #1 as a complaint according to agency policies. c. Agency policy on Grievance Procedure, Patient Complaints directed in part that the agency will investigate complaints made by the patient, legal representative, caregiver and/or family to include treatment or care furnished inappropriately or inconsistently. The staff receiving the complaint shall document the patient complaint, the Executive Director or Clinical Director interviews the patient, family and involved staff and takes appropriate actions to resolve the issue.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: The Condition for 42 CFR 484.55 Comprehensive assessment of patients G 510 was not met when the facility failed to ensure comprehensive assessments were conducted as required. Refer to G 544, 546 and 548 Refer to G 544, 546 and 548

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 review of the clinical record, interview with agency personnel and review of agency policies, for three of six patients (Patient’s #4, #5 and #6) in the survey sample, the agency nurse failed to update the comprehensive assessments every sixty days. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification periods of 7/20/21 through 9/18/21 and 9/19/21 to 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM identified that Patient #4 had a hospital admission from 7/28/21 to 8/11/21 but failed to identify the completion of a Transfer OASIS by RN #1 upon admission to the hospital. b. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM indicated that the last recertification assessment was completed on 9/07/21 (forty-nine days after the start of the certification period) and failed to identify the completion of the assessment in a timely manner. c. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify the completion of the next recertification assessment after 11/17/21. 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM failed to identify the completion of the two subsequent recertification assessments after 8/20/21. 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM failed to identify the completion of the next recertification assessment after 11/05/21. Subsequent to surveyor inquiry, in an interview with the Administrator on 11/22/21 at 12:30 PM, ninety-six patients (Patient’s #7-103) were also affected by late recertification assessments. Agency policy for patient assessments of patients directed that a qualified clinician performs a periodic reassessment visit at least every sixty days.

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 review of the clinical record, interview with agency personnel, and review of agency policies, for three of six patients (Patient’s #4, #5 and #6) in the survey sample, the agency nurse failed to follow agency policies for updating the comprehensive assessment within the last five days of the previous sixty-day certification period. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification period of 9/19/21 through 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify an RN visit between 9/14/21 and 9/18/21 (the last five days of the recertification period ending on 9/18/21) to update and/or revise the comprehensive assessment. b. Further review of the nurse’s notes indicated that the revised assessment was not completed by RN #1 until 9/21/21, two days into the certification period instead of being completed during the last five days of the previous recertification period (prior to 9/19/21). 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM failed to identify an RN visit between 6/17/21 and 6/21/21 (the last five days of the recertification period ending on 6/21/21) to update and/or revise the comprehensive assessment. b. Further review of the nurse’s notes indicated that the revised assessment was completed by RN #1 on 6/22/21, one day into the certification period instead of being completed during the last five days of the previous recertification period (prior to 6/21/21). 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM failed to identify an RN visit between 9/02/21 and 9/06/21 (the last five days of the recertification period ending on 9/06/21) to update and/or revise the comprehensive assessment. b. Further review of the nurse’s notes indicated that the revised assessment was completed by RN #2 on 8/31/21, seven days prior to the certification period instead of being completed during the last five days of the previous recertification period (prior to 9/07/21). Agency policy for patient assessments of patients directed that a qualified clinician performs a periodic reassessment visit during the last five days of the recertification, or at least every sixty days.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on review of the clinical record, interview with agency personnel and review of agency policies, for one of six patients (Patient #4) in the survey sample, the agency nurse failed to revise the comprehensive assessment after a hospital admission. The finding includes: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification period of 9/19/21 through 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM identified that Patient #1 had a hospital admission from 7/28/21 to 8/11/21 but failed to identify the completion of a Resumption of Care/ROC OASIS assessment within forty-eight hours of the patient’s return home from the hospital admission on 8/11/21.

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: The Condition 42 CFR 484.58 Care planning, coordination of services, and quality of care G 570 was not met when the facility failed to ensure the completion of the physician-certified plan of care no less frequently than every sixty days. Refer to G 588 Refer to G 588

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on review of the clinical record, interview with agency personnel and review of agency policies, for three of six patients (Patient’s #4, #5 and #6) in the survey sample, the agency nurse failed to ensure the completion of the physician-certified plan of care no less frequently than every sixty days. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification periods of 7/20/21 through 9/18/21 and 9/19/21 to 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM indicated that the last revision to the plan of care was completed on 9/07/21 (forty-nine days after the start of the certification period) and failed to identify the completion of the plan of care in a timely manner. b. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify the completion of the subsequent review of the plan of care after 11/17/21. 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM identified that the patient continued to receive daily nursing visits for medication administration but failed to identify the completion of the two subsequent reviews of the plan of care after 8/20/21. 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM identified that the patient continued to receive daily nursing visits for medication administration but failed to identify the completion of the two subsequent reviews of the plan of care after 11/05/21. Subsequent to surveyor inquiry, in an interview with the Administrator on 11/22/21 at 12:30 PM, ninety-six patients (Patient’s #7-103) were also affected by late completion of the physician plans of care. Review of the Plan of Care policy directed that a plan of care is developed for all patients and updated no less than every sixty days. A written summary of the patient's condition, outcome to treatment, response to treatment and progress towards goals is completed at least every sixty days and sent to the physician.

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: The Condition for 42 CFR 484.75 Skilled professional services G 700 is not met. The facility failed to follow agency policies on missed visits, failed to ensure the care delivered was in accordance with the physician's orders and failed to communicate with physicians involved in the plan of care. Refer to G 702, 710, 718 Refer to G 702, 710, 718

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of six patients (Patient #1) in the survey sample, the agency nurses failed to follow agency policies on missed visits. The findings include: 1. Patient #1 had a start of care date of 3/22/21 and diagnoses that included hypertension, asthma and depression. The physician's orders for the certification period of 9/18/21 through 11/16/21 included nursing services one time a week for weekly medication pre-pouring and general assessments. a. Interview and review of the clinical record with the former Administrator on 11/19/21 at 11:30 AM identified on 10/06/21, LPN #1 documented a missed visit indicating that the patient was not home/not found. LPN #1 documented that case manager, RN #1, was notified but failed to document notification to the office to have the visit rescheduled and/or notifying the Police Department to conduct a wellness visit in accordance with agency expectations. b. The agency was notified on 10/11/21 that the patient was found deceased in the home. c. Interview with LPN #1 on 11/22/21 at 10 AM indicated that s/he was scheduled to see Patient #1 on Tuesday 10/05/21, the patient was not home, s/he called and left a message regarding the visit scheduled therefore, s/he returned the next day to conduct another visit, again the patient was not home but indicated that the Police Department should have been notified and a wellness check conducted. d. According to the former Administrator, agency expectations for missed visits is to call the patient if not answering the door, notify the office of the missed visit and the need to reschedule a visit for the next day, make another visit the next day and if no answer, call the Police Department for a wellness check. Agency policy on coordination of care directed that all clinicians will report within one business day, missed visits and changes to the scheduled visits.

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 clinical record review and interview with agency personnel, for one of six patients (Patient #1) who required medication management, the agency nurses failed to ensure the care delivered was in accordance with the physician's orders. The finding includes: 1. Patient #1 had a start-of-care date of 3/22/21 and diagnoses that included hypertension, asthma and depression. The physician's orders for the certification period of 9/18/21 through 11/16/21 included nursing services one time a week for weekly medication pre-pouring and general assessments. a. Interview and review of the clinical record with the Administrator on 11/19/21 at 12:30 PM identified on 10/06/21, LPN #1 documented a missed visit indicating that the patient was not home/not found but failed to notify the physician of the alteration in the plan of care.

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 review of the clinical record, interview with agency personnel and review of agency policies, for three of six patients (Patient’s #4, #5 and #6) in the survey sample, the agency nurses failed to communicate with physician’s involved in the plan of care. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification periods of 7/20/21 through 9/18/21 and 9/19/21 to 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify communication with the physician on the need to continue services after 11/17/21 and failed to identify a recertification of the physician’s plan of care. 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM failed to identify communication with the physician on the need to continue services after 8/20/21 and failed to identify a recertification of the physician’s plan of care. 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM failed to identify communication with the physician on the need to continue services after 11/05/21 and failed to identify a recertification of the physician’s plan of care. Subsequent to surveyor inquiry, in an interview with the Administrator on 11/22/21 at 12:30 PM, ninety-six patients (Patient’s #7-103) were also affected by late/absent physician’s orders. Agency policy on plan of care directed that a plan of care is developed for all patient's and updated no less than every sixty days. A written summary of the patient's condition, outcome to treatment, response to treatment and progress towards goals is completed at least every sixty days and sent to the physician.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: The Condition for 42 CFR 484.105 Organization and administration of services G 940 was not met. The Governing Body and Administrator failed to ensure the provision of all home health services including patient safety through updates of the comprehensive assessments and plans of care, failed to ensure the Clinical Manager coordinated care to meet the patient’s needs, and failed to ensure the clinical notes were incorporated into the electronic record within twenty-four hours of the visit. Refer to G 942, 948, 958, 1024 Refer to G 942, 948, 958, 1024

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on clinical record review and interview with agency personnel for ninety-nine patients who required recertification for home care services (Patient’s #4, 5 and 6), the Governing Body failed to ensure the provision of all home health services and patient safety through updates of the comprehensive assessments and plans of care. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification periods of 7/20/21 through 9/18/21 and 9/19/21 to 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM identified that Patient #1 had a hospital admission from 7/28/21 to 8/11/21 but failed to identify the completion of a Transfer OASIS by RN #1 upon admission to the hospital. b. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM indicated that the last recertification assessment was completed on 9/07/21 (forty-nine days after the start of the certification period) and failed to identify the completion of the assessment in a timely manner. c. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify the completion of the next recertification assessment after 11/17/21. 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM failed to identify the completion of the two subsequent recertification assessments after 8/20/21. 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM failed to identify the completion of the next recertification assessment after 11/05/21. On 9/07/21, the Clinical Manager resigned as well as SCS #1 (from Branch #2) who were responsible for nursing oversight of Branch #2, two RN’s resigned over the summer leaving ninety-three patients (out of a census of 235) without a primary care nurse. Subsequently, the ninety-three (93) patients have been reassigned and fifty-four (54) of them have been assigned to SCS #2 from Branch #1. Interview with the Administrator on 11/22/21 at 11:45 AM, indicated that on 8/09/21, s/he became aware of the overdue re-certifications/reassessments. Ninety-six patients (Patient’s #7-103) were also affected by late recertification assessments. The Administrator met with SCS #1 (Branch #2) who was placed on a Corrective Action Plan/CAP to ensure all staff are oriented and monitored for compliance with performance expectations; supervises daily office activities to ensure that effective and efficient operations are in place and is responsible for teamwork and collaboration.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel for ninety-nine patients who required recertification for home care services (Patient’s #4, 5 and 6), the Agency Administrator failed to ensure the provision of all home health services and patient safety through updates of the comprehensive assessments and plans of care. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification periods of 7/20/21 through 9/18/21 and 9/19/21 to 11/17/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM identified that Patient #1 had a hospital admission from 7/28/21 to 8/11/21 but failed to identify the completion of a Transfer OASIS by RN #1 upon admission to the hospital. b. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM indicated that the last recertification assessment was completed on 9/07/21 (forty-nine days after the start of the certification period) and failed to identify the completion of the assessment in a timely manner. c. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify the completion of the next recertification assessment after 11/17/21. 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM failed to identify the completion of the two subsequent recertification assessments after 8/20/21. 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM failed to identify the completion of the next recertification assessment after 11/05/21. Subsequent to surveyor inquiry, in an interview with the Administrator on 11/22/21 at 12:30 PM, ninety-six patients (Patient’s #7-103) were also affected by late recertification assessments. Furthermore, in an interview with SCS #2 (Branch #1) on 11/22/21 at 10 AM, indicated that on 9/07/21, the Clinical Manager resigned as well as SCS #1 (from Branch #2) who were responsible for nursing oversight of Branch #2 and indicated that two RN’s resigned over the summer leaving ninety-three patients (out of a census of 235) without a primary care nurse. Subsequently, the ninety-three (93) patients have been reassigned and fifty-four (54) of them have been assigned to SCS #2 from Branch #1.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on clinical record review and interview with agency personnel for ninety-nine patients who required recertification for home care services (Patient’s #4, 5 and 6), the Clinical Manager failed to ensure the coordination of care to meet the patient’s needs. The findings include: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification periods of 7/20/21 through 9/18/21 and 9/19/21 to 11/17/21 included nursing services two times a day for medication administration and general assessments. i. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM identified that Patient #1 had a hospital admission from 7/28/21 to 8/11/21 but failed to identify the completion of a Transfer OASIS by RN #1 upon admission to the hospital. ii. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM indicated that the last recertification assessment was completed on 9/07/21 (forty-nine days after the start of the certification period) and failed to identify the completion of the assessment in a timely manner. iii. Interview and review of the nursing documentation with the Supervisor of Clinical Services/SCS #2 on 11/22/21 at 11 AM failed to identify the completion of the next recertification assessment after 11/17/21. 2. Patient #5 had a start of care date of 4/23/21 and diagnoses that included schizophrenia and asthma. The physician's orders for the certification period of 6/22/21 through 8/20/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:05 AM failed to identify the completion of the two subsequent recertification assessments after 8/20/21. 3. Patient #6 had a start of care date of 3/11/21 and diagnoses that included type II diabetes mellitus, schizoaffective disorder and anxiety. The physician's orders for the certification period of 9/07/21 through 11/05/21 included nursing services seven times a week for medication administration and general assessments. a. Interview and review of the nursing documentation with SCS #2 on 11/22/21 at 11:10 AM failed to identify the completion of the next recertification assessment after 11/05/21. Subsequent to surveyor inquiry, in an interview with the Administrator on 11/22/21 at 12:30 PM, ninety-six patients (Patient’s #7-103) were also affected by late recertification assessments. Furthermore, in an interview with SCS #2 (Branch #1) on 11/22/21 at 10 AM, indicated that on 9/07/21, the Clinical Manager resigned as well as SCS #1 (from Branch #2) who were responsible for nursing oversight of Branch #2 and indicated that two RN’s resigned over the summer leaving ninety-three patients (out of a census of 235) without a primary care nurse. Subsequently, the ninety-three (93) patients have been reassigned and fifty-four (54) of them have been assigned to SCS #2 from Branch #1.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on a review of clinical records, interview with agency personnel and review of agency policies, for one of six patients (Patient #4) in the survey sample, the agency nurses failed to ensure the clinical notes were incorporated into the electronic record within twenty-four hours of the visit. The finding includes: 1. Patient #4 had a start of care date of 2/18/16 and diagnoses that included schizoaffective and bipolar disorders. The physician's orders for the certification period of 7/21/21 through 9/18/21 included nursing services two times a day for medication administration and general assessments. a. Interview and review of the clinical record with the Administrator on 11/22/21 at 2:30 PM identified the late submission of nursing notes dated 7/25/21, 8/20/21, 8/21/21, 8/29/21, 9/11/21, 9/12/21 and 9/18/21 and failed to ensure timely and authentic submission of nursing notes according to agency policies. Agency policy on coordination of care directed that completed visit notes will be submitted to the agency via synchronization within twenty-four (24) hours of the visit.