Every finding on record at Professional Home Services Inc

During the recertification survey conducted on 02/14/2024 to 02/16/2024 at Professional Home Services Inc., a Home Health Agency, Emergency Preparedness was reviewed. Professional Home Services Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 02/14/2024 to 02/16/2024 at Professional Home Services Inc. The home health agency was in non-compliance with 42 Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for Home Health Agencies.

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: Based on observation and interview, the home health agency staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 1 out of 3 Sampled patients (SP) with home visits made. SP #1 Findings include: During a home visit made to SP#1 on 02/15/2024 at 9:58am surveyor observed Staff F (Registered Nurse) cleanse hands and then place gloves on. Patient has 2 wounds one on back and one leg area. The nurse removed the old dressing from back, only took off right glove, placed new glove on and cleansed wound with saline and patted dry. Again, only removed right glove and placed new glove on took Neosporin removed cap and then placed some on right index finger and placed directly on wound and then put gauze over and paper tape. Removed only right glove again and placed clean glove and removed old dressing from leg, changed right glove again and washed wound with saline, changed glove on right hand only again and put on clean glove and preformed same step. Opened up Neosporin place small amount on right hand finger tip and put that directly on wound. Changed glove again and put on dry sterile dressing and paper tape. Surveyor conducted an interview with Director of nursing, administrator and alternate administrator on 02/16/2024 between 11:50am-12:35pm and confirmed that staff F failed to maintain infection control when providing wound care to Sample Patient #1.

During the recertification survey conducted on 01/04/2021 to 01/07/2021 at Professional Home Services, Inc. a Home Health Agency, Emergency preparedness was reviewed. Professional Home Services, Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies. The following is a description of the non-compliance:

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to develop and maintain an emergency preparedness plan that is based on and include a documented, facility-based and community-based risk assessment, utilizing an all hazards approach and that include strategies for addressing emergency events identified by the risk assessment. Findings include: Record review conducted on 01/06/2021 at 1:00 PM revealed no documentation showing that the agency developed and maintained an emergency preparedness plan that is based on and include a documented, facility-based and community-based risk assessment, utilizing an all hazards approach and that include strategies for addressing all the emergency events identified by the risk assessment. During an interview conducted on 01/07/2021 at 9:31 AM, the Administrator/Alternate Director of Nursing reviewed the emergency preparedness binders and acknowledged the findings.

Development of EP Policies and Procedures CFR(s): 484.102(b) (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the provider failed to develop and implement federal emergency preparedness policies and procedures based on all the risks which were identified on its risk assessment. Findings include: Record review conducted on 01/06/2021 at 1:00 PM revealed the agency identified hurricanes, tornadoes, flood, fire, civil disorders, heat, thunderstorm and epidemic/pandemic on its risk assessment. Further review of the agency's emergency plan revealed no documentation that the agency developed a policy and procedure for each of the risks which were identified by the risk assessment. During an interview conducted on 01/07/2021 at 9:33 AM, the Administrator/Alternate Director of Nursing reviewed the manual and acknowledged that the agency did not develop and implement emergency preparedness policies and procedures based on all the risks which were identified on its risk assessment.

EP Training Program CFR(s): 484.102(d)(1) *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to conduct training in its emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Findings include: Review of Staff A, Staff B, Staff C, Staff D, Staff E, Staff F, Staff G, Staff H, Staff I and Staff J's personnel records conducted on 01/07/2021 revealed the agency used the same generalized emergency test for all its employees. Further record review revealed no documentation that the agency tested the employees' knowledge of its federal emergency preparedness plan based on their expected/respective roles should an emergency arise. During an interview conducted on 01/07/2021 at 12:51 PM, the Administrator acknowledged that the agency did not test Staff F, Staff G, Staff H, Staff I and Staff J's knowledge of its federal emergency plan based on their expected/respective roles should an emergency arise.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to conduct exercises to ensure all its employees participated in a tabletop exercise or workshop that is led by a facilitator. Findings include: Record review on 01/06/2021 at 1:00 PM revealed the agency conducted a tabletop exercise on 01/06/2020. Further record review revealed only the following participants attended the in-service: The Administrator/Alternate Director of Nursing, the Alternate Administrator, the Director of Nursing, the office manager, the medical record keeper and three field staff representatives. Additional record review revealed no documentation that any other employees attended the tabletop exercise on 01/06/20. During an interview conducted on 01/07/2021 at 9:29 AM, the Administrator/Director of Nursing reviewed the emergency plan and acknowledged that all its employees did not participate in the tabletop exercise on 01/06/2020.

A recertification survey was conducted on January 04, 2021 through January 07, 2021 at Professional Home Services, Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to ensure the care follows the written plan of care (POC) established by the physician on 1 out of 3 Sampled Patients (SP). SP#2 Findings include: Clinical record review of the SP#2 conducted on 01/06/21 revealed that SP#2 was seen by physician on 12/16/20 and ordered for wound care to be done every other day frequency. Review of the nursing service notes for date range 12/16/20 to 12/21/20 revealed the nursing visits were provided on 12/17/20, 12/18/20 and 12/21/20. Telephone interview conducted on 01/06/21 at 2:15 PM with the Registered Nurse (RN) providing care to SP#2. The RN answered that he really doesn't remember exactly what happened, but it could be that RN could not go on the 12/20/20 and therefore he called the patient to check up and the patient stated that the dressing was dry, then RN informed patient that he would go until 12/21/20 to provide the wound care. Interview conducted with the Alternate Director of Nursing on 01/07/21 at 12:29 PM stated she spoke with the nurse and provided the same information as stated above. The Alternate Director of Nursing confirmed that the nurse did not follow the physician order in providing the wound care every other day.

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, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to develop complete policies and procedures on the Influenza and Pneumococcal vaccines with the consultation of a physician. Findings include: Review of the Home Health Agency's policy manual on 01/07/2021 at 11:54 AM revealed a form titled "Patient Vaccination: Influenza and Pneumococcal Vaccines". Further review of the form revealed no documentation that the agency developed written policies and procedures concerning how the agency would manage any patients' adverse reactions if any, post the influenza/pneumococcal vaccines administration. During an interview conducted on 01/07/2021 at 1:31 PM, the Administrator acknowledged that the agency did not develop written policies and procedures on the influenza/pneumococcal vaccines that addressed how the agency would manage any patients' adverse reactions if any after vaccines administration post the influenza/pneumococcal vaccines administration.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to assure communication with the patient's physician involved in the plan of care for 1 out of 10 Sampled Patients (SP). SP#5 Findings include: Clinical record review conducted on 01/05/21 and 01/06/21 revealed a Plan of Care (POC) for certification period of 12/05/20 to 02/02/21 that reads "SN (skilled nurse) to monitor blood glucose levels and administer insulin injection as ordered by MD (medical doctor) (refer to medication box on POC)." Review of the medications listed in the medication box of the POC reads "Novolog Mix 70/30 subcutaneous 20 units with meals (C)(change) and Levemir subcutaneous 20 units daily at 9 pm." Review of the skilled nursing service notes for date range 11/08/20 to 12/31/20 revealed the nurse provides morning visit of a time range of 8:00 am to 9:50 am and then a afternoon visit of a time range of 4:25 pm to 6:05 pm. Further review of the documentation by the skilled nursing for service notes date range 11/08/20 to 12/31/20 showed that Novolog Mix 70/30 is administered in the morning and afternoon, and Levemir is administered in the afternoon. The clinical record omitted documentation for the reason the Levemir is being administered as early as 4:25 pm and not at 9 pm as ordered by the physician. Further review of the clinical record omitted clarification of the insulin Novolog Mix 70/30 that reads with meals and is only being administered in the morning and afternoon; no reason documented for not providing insulin at lunch time (a time of meals). Telephone interview conducted on 01/04/21 at 1:34 PM with the Registered Nurse (Staff M) providing care to SP#5. As per Staff M he provides insulin in AM and PM only, given Novolog in AM and PM, and Levemir in PM. The Staff M clarified that patient only takes the insulin administered by the nurse and no one else provides further insulin. The surveyor reviewed medication Novolog as documented on the POC, to be provided with "meals", therefore was is to be given at AM, NOON, and PM. The Staff M stated that patient has never had three times a day, and by his interpretation, with meals meaning that patient takes the insulin when he has his food, but that the patient could not handle three times a day insulin injections, that would be too much for him. The surveyor inquired if Staff M verified with the ordering physician about the frequency of Novovlog, the Staff M answered "no", that he has never spoken to the doctor but he has been taking care of the patient for a long time and the insulin has always has been given in AM and PM and there has been no issue. Interview conducted on 01/07/21 at 12:25 PM with Alternate Director of Nursing stated that she spoke with the ordering physician yesterday about the Novolog, and the physician stated that it can only be given twice, and that Levemir can be administered in the afternoon. The Alternate Director of Nursing agreed that the clarification from the beginning was missed, and the physician has given the corrected order now. The Alternate Director of Nursing provided surveyor a copy of the clarification order obtained 01/06/21.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate the staff(s) prepare and record clinical notes for 1 out of 10 Sampled Patients (SP). SP#8 Findings include: Electronic clinical record review conducted on 01/05/21 of SP#8 revealed the patient was admitted on 12/04/20 with a Plan of Care ordering skilled nursing service and physical therapy service. Further review of the electronic clinical record revealed the physical therapist assistant has not completed the scheduled visit notes of dates 12/24/20, 12/29/20 and 12/31/20. The scheduled visit notes for dates 12/24/20, 12/29/20 and 12/31/20 revealed status as "Not Started". Interview conducted with the Alternate Director of Nursing on 01/07/21 at 12:52 PM acknowledged findings made by the surveyor, failure of the provider to have a complete clinical record with all the notes for care rendered.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to maintain the content of a clinical record that includes all interventions including services rendered by the home health agency staff for 2 out of 10 Sampled Patients (SP). SP#1 and SP#7 Findings include: Clinical record review conducted on 01/06/21 of SP#1 revealed a physician order dated 12/22/2020 reads "SN (skilled nurse) to prepare and administer Meropenem 1 gram intravenous over 30 minutes in the AM (morning) and PM (afternoon). Daptomycin intravenous 500 mg daily. SN to apply betadine wet to dry dressing to right foot surgical wound, wrap with light ace bandage every other day." Review of the skilled nurse service notes for date 12/23/20 revealed the nurse documented as providing Daptomycin in the morning and afternoon. Further review of the service notes for dates 01/01/21, 01/02/21 and 01/03/21 revealed the nurse documented as providing wound care daily. Telephone interview was conducted on 01/06/21 at 1:48 PM with SP#1. The SP#1 confirmed that the nurse provides Meropenem twice a day and Daptomycin in the afternoon. The SP#1 further added that the nurse provides wound care every other day, last done by nurse on Sunday. The patient stated that he had an doctor's appointment on Tuesday and they performed the wound care in the office since they have to evaluate the wound. Clinical record review conducted on 01/05/21 of SP#7 revealed an admission date of 11/30/20 with a Plan of Care that reads "Patient diagnosed with COVID19 and Pneumonia. SN (skilled nurse) to assess O2 (oxygen) saturation on room air as needed." Review of the skilled nurse service notes for date range 12/02/20 to 12/24/20 revealed no documentation by the nurse of O2 saturation being assessed. Telephone interview conducted on 01/06/21 at 1:07 PM with the Registered Nurse (RN / Staff F ) providing care to SP#7 stated that he obtains the patient's vitals and makes total body assessments. The surveyor inquired what are the vitals he obtains. The RN stated blood pressure, respiration, heart rate and O2 saturation reading. The surveyor informed the RN that service notes for date range 12/02/20 to 12/24/20 omitted the O2 saturation readings. The RN stated that he does obtain O2 readings and added "sorry missed to write it in the notes". Interview conducted with the Alternate Director of Nursing on 01/07/21 at 12:52 PM confirmed that the provider failed to maintain clinical records with accurate and complete documentation of all interventions rendered to patients by staff.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to ensure the clinical record included a completed 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 Home Health Agency (if any) within 5 business days of the patient's discharge for 2 out of 10 Sampled Patients. SP#9 and SP#10 Findings include: Closed record reviews of SP#9 and SP#10 conducted on 01/04/21 revealed a discharge summary dated 11/24/20 for SP#9 and a discharge summary dated 12/07/20 for SP#10 that were incomplete and omitted the patient's condition at discharge; the patient's care summary was incomplete and the outcomes in meeting the goals in the plan of care. Interview conducted with the Alternate Director of Nursing on 01/07/21 at 12:52 PM acknowledged that the discharge summaries for SP#9 and SP#10 were incomplete.

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 record review and interview, the provider failed to ensure the clinical record includes all entries appropriately authenticated (signature and a title), dated, and timed for 2 out 10 Sampled Patient (SP). SP#3 and SP#5 Findings include: Electronic clinical record review conducted on 01/05/21 of SP#3 revealed the Registered Nurse has not authenticated the entry of an assessment titled "Recertfication" with visit date 12/07/20 and under status read "Pending Clinician Signature". Electronic clinical record review conducted on 01/05/21 of SP#5 revealed the Registered Nurse has not authenticated the entry of an assessment titled "Recertfication" with visit date 12/01/20 and under status read "Pending Clinician Signature". Interview conducted with the Alternate Director of Nursing on 01/07/21 at 12:18 PM stated that the nurse opened the recertification assessment to add information and forgot to sign it again. The Alternate Director of Nursing added that the nurse has signed the recertification as of last night. Interview conducted with the Alternate Director of Nursing on 01/07/21 at 12:52 PM acknowledged findings made by the surveyor, failure of the provider to have a complete clinical record with all entries appropriately authenticated.